Provider Demographics
NPI:1811642796
Name:TSHIBANGU, MARLENE
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:TSHIBANGU
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 1:7602 FONTAINEBLEAU DR APT 242
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3812
Mailing Address - Country:US
Mailing Address - Phone:202-247-8194
Mailing Address - Fax:
Practice Address - Street 1:7602 FONTAINEBLEAU DR APT 242
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3812
Practice Address - Country:US
Practice Address - Phone:202-247-8194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00196191367500000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty