Provider Demographics
NPI:1770097503
Name:NDIKUM NDIFOR, LACKALONG
Entity type:Individual
Prefix:
First Name:LACKALONG
Middle Name:
Last Name:NDIKUM NDIFOR
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 1:8627 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3108
Mailing Address - Country:US
Mailing Address - Phone:302-423-4568
Mailing Address - Fax:
Practice Address - Street 1:8627 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3108
Practice Address - Country:US
Practice Address - Phone:302-423-4568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
DCHHA13240374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No374U00000XNursing Service Related ProvidersHome Health Aide