Provider Demographics
NPI:1790597235
Name:MBIATAT, FREDERICK CHUMFONG
Entity type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:CHUMFONG
Last Name:MBIATAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4645 NANNIE HELEN BURROUGHS AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-3622
Mailing Address - Country:US
Mailing Address - Phone:202-733-4904
Mailing Address - Fax:202-733-4879
Practice Address - Street 1:4645 NANNIE HELEN BURROUGHS AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3622
Practice Address - Country:US
Practice Address - Phone:202-733-4904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN50002044164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty