Provider Demographics
NPI:1821544511
Name:FAMOUS, PRINCE OMORERE
Entity Type:Individual
Prefix:MR
First Name:PRINCE
Middle Name:OMORERE
Last Name:FAMOUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 64TH AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1818
Mailing Address - Country:US
Mailing Address - Phone:301-765-4351
Mailing Address - Fax:
Practice Address - Street 1:3811 64TH AVE
Practice Address - Street 2:APT 4
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20784-1818
Practice Address - Country:US
Practice Address - Phone:301-765-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12302374U00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No374U00000XNursing Service Related ProvidersHome Health Aide