Provider Demographics
NPI:1912781360
Name:NNABUKO, EMMANUEL GIDEON
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:GIDEON
Last Name:NNABUKO
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 1:2660 HUSK PL APT 101
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-1806
Mailing Address - Country:US
Mailing Address - Phone:240-510-6421
Mailing Address - Fax:
Practice Address - Street 1:2660 HUSK PL APT 101
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-1806
Practice Address - Country:US
Practice Address - Phone:240-510-6421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106S00000X
DCHHA200003807374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide