Provider Demographics
NPI:1912368408
Name:MIRIAM, BOSASA AYAMBA
Entity Type:Individual
Prefix:
First Name:BOSASA AYAMBA
Middle Name:
Last Name:MIRIAM
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 1:6305 IVY LN STE 610
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-6363
Mailing Address - Country:US
Mailing Address - Phone:202-790-8903
Mailing Address - Fax:301-889-9735
Practice Address - Street 1:6305 IVY LN STE 610
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-6363
Practice Address - Country:US
Practice Address - Phone:202-790-8903
Practice Address - Fax:301-889-9735
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRBT-22-200229106S00000X
DCHHA11692374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician