Provider Demographics
NPI:1265958276
Name:KIBANG, CLIFFORD WAKHA (HHA)
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:WAKHA
Last Name:KIBANG
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3271 QUEENSTOWN DR APT 201
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-1082
Mailing Address - Country:US
Mailing Address - Phone:240-413-1428
Mailing Address - Fax:
Practice Address - Street 1:3271 QUEENSTOWN DRIVE
Practice Address - Street 2:APT #201
Practice Address - City:MOUNT RAINIER
Practice Address - State:MD
Practice Address - Zip Code:20712
Practice Address - Country:US
Practice Address - Phone:240-413-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13011374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCHHA13011OtherDC BOARD OF NURSING
DCHHA13011Medicaid