Provider Demographics
NPI:1932890175
Name:KOOMSON, WILLIETTE COMFORT
Entity Type:Individual
Prefix:
First Name:WILLIETTE
Middle Name:COMFORT
Last Name:KOOMSON
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 1:7 RAYLON DR APT D
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4953
Mailing Address - Country:US
Mailing Address - Phone:443-686-2656
Mailing Address - Fax:
Practice Address - Street 1:7 RAYLON DR APT D
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-4953
Practice Address - Country:US
Practice Address - Phone:443-686-2656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRSA-01574251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health