Provider Demographics
NPI:1639978026
Name:MBAH, CARLSON FON
Entity type:Individual
Prefix:
First Name:CARLSON
Middle Name:FON
Last Name:MBAH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6501 WOOD POINTE DR
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-2116
Mailing Address - Country:US
Mailing Address - Phone:240-260-8979
Mailing Address - Fax:
Practice Address - Street 1:6501 WOOD POINTE DR
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-2116
Practice Address - Country:US
Practice Address - Phone:240-260-8979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide