Provider Demographics
NPI:1992041057
Name:MBABOU, IDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:MBABOU
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 1:1902 FOX ST APT 104
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2356
Mailing Address - Country:US
Mailing Address - Phone:240-595-8142
Mailing Address - Fax:
Practice Address - Street 1:7506 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1608
Practice Address - Country:US
Practice Address - Phone:202-291-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide