Provider Demographics
NPI:1851867816
Name:KINFACK, IVAN LAUTRY
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:LAUTRY
Last Name:KINFACK
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 1:3809 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:LANDOVER HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1816
Mailing Address - Country:US
Mailing Address - Phone:202-306-9773
Mailing Address - Fax:
Practice Address - Street 1:3809 64TH AVE
Practice Address - Street 2:
Practice Address - City:LANDOVER HILLS
Practice Address - State:MD
Practice Address - Zip Code:20784-1816
Practice Address - Country:US
Practice Address - Phone:202-306-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant