Provider Demographics
NPI:1952070401
Name:KENSONG TIBA, ELVINE C
Entity Type:Individual
Prefix:
First Name:ELVINE
Middle Name:C
Last Name:KENSONG TIBA
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 1:1533 HUNTER RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4609
Mailing Address - Country:US
Mailing Address - Phone:301-331-8498
Mailing Address - Fax:
Practice Address - Street 1:1533 HUNTER RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-4609
Practice Address - Country:US
Practice Address - Phone:301-331-8498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide