Provider Demographics
NPI:1891161097
Name:FONGANG, MICHEL
Entity Type:Individual
Prefix:
First Name:MICHEL
Middle Name:
Last Name:FONGANG
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 1:6120 KANSAS AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1531
Mailing Address - Country:US
Mailing Address - Phone:202-722-1234
Mailing Address - Fax:
Practice Address - Street 1:6120 KANSAS AVE NE APT 301
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1531
Practice Address - Country:US
Practice Address - Phone:202-722-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11472374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide