Provider Demographics
NPI:1205172277
Name:WANDJI KOUATCHO, NELLY
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:WANDJI KOUATCHO
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 1:1029 QUEBEC TER
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-3139
Mailing Address - Country:US
Mailing Address - Phone:240-491-7247
Mailing Address - Fax:
Practice Address - Street 1:439 ONEIDA PL NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-2150
Practice Address - Country:US
Practice Address - Phone:202-291-7226
Practice Address - Fax:202-291-4009
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC036061400Medicaid