Provider Demographics
NPI:1295540748
Name:MBOLLE, EBONG (MD)
Entity type:Individual
Prefix:
First Name:EBONG
Middle Name:
Last Name:MBOLLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7004 HIGHVIEW TER APT 101
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-4026
Mailing Address - Country:US
Mailing Address - Phone:202-644-0460
Mailing Address - Fax:
Practice Address - Street 1:7004 HIGHVIEW TER APT 101
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-4026
Practice Address - Country:US
Practice Address - Phone:202-644-0460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAOO213488376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide