Provider Demographics
NPI:1932465002
Name:AZONGHO, ANSELM (LPN)
Entity Type:Individual
Prefix:
First Name:ANSELM
Middle Name:
Last Name:AZONGHO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6003 67TH AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-1756
Mailing Address - Country:US
Mailing Address - Phone:301-377-8182
Mailing Address - Fax:
Practice Address - Street 1:6003 67TH AVE
Practice Address - Street 2:APT 3
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1756
Practice Address - Country:US
Practice Address - Phone:301-377-8182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN1005237164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse