Provider Demographics
NPI:1952047656
Name:YEBOAH, DORA
Entity Type:Individual
Prefix:
First Name:DORA
Middle Name:
Last Name:YEBOAH
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 1:4834 AUTUMN GLORY WAY
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2352
Mailing Address - Country:US
Mailing Address - Phone:703-263-0861
Mailing Address - Fax:703-968-3942
Practice Address - Street 1:4834 AUTUMN GLORY WAY
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-2352
Practice Address - Country:US
Practice Address - Phone:703-263-0861
Practice Address - Fax:703-968-9293
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1629339700Medicaid