Provider Demographics
NPI:1831763218
Name:FONYONGA, BINTA I
Entity type:Individual
Prefix:
First Name:BINTA
Middle Name:I
Last Name:FONYONGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BINTA
Other - Middle Name:IJANG
Other - Last Name:FONYONGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11337 DRUMSHEUGH LN
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5749
Mailing Address - Country:US
Mailing Address - Phone:301-675-3847
Mailing Address - Fax:
Practice Address - Street 1:6495 NEW HAMPSHIRE AVE STE A303
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3245
Practice Address - Country:US
Practice Address - Phone:240-825-3153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00185588374U00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide