Provider Demographics
NPI:1831929421
Name:BONGO, BERNICE I
Entity type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:BONGO
Suffix:I
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 1:5504 SMITA PL LANHAM
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706
Mailing Address - Country:US
Mailing Address - Phone:240-598-8118
Mailing Address - Fax:
Practice Address - Street 1:5504 SMITA PL LANHAM
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706
Practice Address - Country:US
Practice Address - Phone:240-598-8118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program