Provider Demographics
NPI:1821743436
Name:MAKOUGANG, KEVINE RAISSA II
Entity Type:Individual
Prefix:MS
First Name:KEVINE
Middle Name:RAISSA
Last Name:MAKOUGANG
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 METZEROTT RD APT 1727
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-3452
Mailing Address - Country:US
Mailing Address - Phone:267-339-8410
Mailing Address - Fax:
Practice Address - Street 1:1836 METZEROTT RD APT 1727
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-3452
Practice Address - Country:US
Practice Address - Phone:267-339-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2023-07-27
Deactivation Date:2023-06-26
Deactivation Code:
Reactivation Date:2023-07-11
Provider Licenses
StateLicense IDTaxonomies
MD376K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide