Provider Demographics
NPI:1841789187
Name:GANSORE, ANGE WENDYAM
Entity Type:Individual
Prefix:MRS
First Name:ANGE
Middle Name:WENDYAM
Last Name:GANSORE
Suffix:
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 1:11215 OAK LEAF DR APT 120
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1364
Mailing Address - Country:US
Mailing Address - Phone:304-918-8805
Mailing Address - Fax:
Practice Address - Street 1:11215 OAK LEAF DR APT 120
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1364
Practice Address - Country:US
Practice Address - Phone:304-918-8805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13644374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCHHA13644OtherGOVERNMENT OF THE DISTRICT OF COLUMBIA