Provider Demographics
NPI:1780167635
Name:MUKUM, KELLY ACHOH
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ACHOH
Last Name:MUKUM
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 1:8151 MANDAN TER
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2643
Mailing Address - Country:US
Mailing Address - Phone:240-510-7745
Mailing Address - Fax:
Practice Address - Street 1:6323 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1101
Practice Address - Country:US
Practice Address - Phone:202-506-1209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12839374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide