Provider Demographics
NPI:1023726478
Name:MBONGHO, SHARLINE NYANGA
Entity type:Individual
Prefix:
First Name:SHARLINE
Middle Name:NYANGA
Last Name:MBONGHO
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 1:7765 RIVERDALE RD APT T3
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3928
Mailing Address - Country:US
Mailing Address - Phone:240-790-6716
Mailing Address - Fax:
Practice Address - Street 1:7765 RIVERDALE RD APT T3
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3928
Practice Address - Country:US
Practice Address - Phone:240-790-6716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCNA20223809376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide