Provider Demographics
NPI:1013522721
Name:NGOMBA, ETHEL
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:NGOMBA
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 1:3009 SPICE BUSH RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2921
Mailing Address - Country:US
Mailing Address - Phone:267-663-6292
Mailing Address - Fax:
Practice Address - Street 1:3009 SPICE BUSH RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-2921
Practice Address - Country:US
Practice Address - Phone:267-663-6292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00179378376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide