Provider Demographics
NPI:1922733591
Name:MBIANDA, JUSTINE (CEO)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:MBIANDA
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:MS
Other - First Name:JUSTINE
Other - Middle Name:
Other - Last Name:MBIANDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CEO
Mailing Address - Street 1:13105 COLLINGWOOD TER
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1417
Mailing Address - Country:US
Mailing Address - Phone:301-379-9111
Mailing Address - Fax:301-900-4599
Practice Address - Street 1:13105 COLLINGWOOD TER
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1417
Practice Address - Country:US
Practice Address - Phone:301-803-9690
Practice Address - Fax:301-900-4599
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR4765251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health