Provider Demographics
NPI:1831762632
Name:KIMBAM, NEOLA
Entity type:Individual
Prefix:
First Name:NEOLA
Middle Name:
Last Name:KIMBAM
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 1:5422 54TH AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-2324
Mailing Address - Country:US
Mailing Address - Phone:240-462-2907
Mailing Address - Fax:
Practice Address - Street 1:5422 54TH AVE APT 6
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-2324
Practice Address - Country:US
Practice Address - Phone:240-462-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA15908374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide