Provider Demographics
NPI:1932640638
Name:MBAKU STELLA, NGWE
Entity Type:Individual
Prefix:
First Name:NGWE
Middle Name:
Last Name:MBAKU STELLA
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 1:4805 LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705
Mailing Address - Country:US
Mailing Address - Phone:301-529-0482
Mailing Address - Fax:
Practice Address - Street 1:4805 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1528
Practice Address - Country:US
Practice Address - Phone:301-529-0482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12689374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1134956860Medicaid