Provider Demographics
NPI:1205300274
Name:TANONKO MAFEUGONG, LINE SANDRA SANDRA
Entity type:Individual
Prefix:
First Name:LINE SANDRA
Middle Name:SANDRA
Last Name:TANONKO MAFEUGONG
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 1:1804 FOX ST APT 202
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2348
Mailing Address - Country:US
Mailing Address - Phone:864-395-7062
Mailing Address - Fax:
Practice Address - Street 1:1010 VERMONT AVE NW STE 1003
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-4927
Practice Address - Country:US
Practice Address - Phone:844-381-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDT-552-522-014-9013747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant