Provider Demographics
NPI:1255936654
Name:ATABONGAKENG, PRUDENCIA
Entity type:Individual
Prefix:MRS
First Name:PRUDENCIA
Middle Name:
Last Name:ATABONGAKENG
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 1:899 N CAPITOL ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-5686
Mailing Address - Country:US
Mailing Address - Phone:240-486-5111
Mailing Address - Fax:
Practice Address - Street 1:3505 ESQUILIN TER
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1277
Practice Address - Country:US
Practice Address - Phone:240-486-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA15092374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide