Provider Demographics
NPI:1669189262
Name:BAGNA, KODOUWARI RAFAHATOU
Entity type:Individual
Prefix:
First Name:KODOUWARI
Middle Name:RAFAHATOU
Last Name:BAGNA
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 1:11215 OAK LEAF DR APT 415
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1367
Mailing Address - Country:US
Mailing Address - Phone:240-423-3645
Mailing Address - Fax:
Practice Address - Street 1:11215 OAK LEAF DR APT 415
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-1367
Practice Address - Country:US
Practice Address - Phone:240-423-3645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCNA20223958376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide