Provider Demographics
NPI:1881272672
Name:FONGANG, PRAXITE
Entity type:Individual
Prefix:
First Name:PRAXITE
Middle Name:
Last Name:FONGANG
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 1:6323 GEORGIA AVE NW STE 350
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1151
Mailing Address - Country:US
Mailing Address - Phone:240-495-4248
Mailing Address - Fax:
Practice Address - Street 1:6323 GEORGIA AVE NW STE 350
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1151
Practice Address - Country:US
Practice Address - Phone:240-495-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
DCHHA15725374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No374U00000XNursing Service Related ProvidersHome Health Aide