Provider Demographics
NPI:1013769850
Name:MBAH, WILFRED ANYAM
Entity Type:Individual
Prefix:
First Name:WILFRED
Middle Name:ANYAM
Last Name:MBAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6903 GOOD LUCK RD
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3620
Mailing Address - Country:US
Mailing Address - Phone:240-854-1073
Mailing Address - Fax:
Practice Address - Street 1:6903 GOOD LUCK RD
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3620
Practice Address - Country:US
Practice Address - Phone:240-854-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA200003700374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide