Provider Demographics
NPI:1881383453
Name:AMBOMU, NICOLAS F
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:F
Last Name:AMBOMU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 ANDEAN GOOSE WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-7129
Mailing Address - Country:US
Mailing Address - Phone:240-883-1023
Mailing Address - Fax:
Practice Address - Street 1:1013 ANDEAN GOOSE WAY
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-7129
Practice Address - Country:US
Practice Address - Phone:240-883-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
No172V00000XOther Service ProvidersCommunity Health Worker