Provider Demographics
NPI:1871024901
Name:KHUMBAH, AGNES
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:KHUMBAH
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 1:12656 HEMING LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1119
Mailing Address - Country:US
Mailing Address - Phone:719-464-2292
Mailing Address - Fax:
Practice Address - Street 1:12656 HEMING LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1119
Practice Address - Country:US
Practice Address - Phone:719-464-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12684374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide