Provider Demographics
NPI:1487085429
Name:EDIMO, KENNETH (HHA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:EDIMO
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9755 GOOD LUCK RD APT 4
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3326
Mailing Address - Country:US
Mailing Address - Phone:703-606-3503
Mailing Address - Fax:202-545-0934
Practice Address - Street 1:9755 GOOD LUCK RD APT 4
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3326
Practice Address - Country:US
Practice Address - Phone:703-606-3503
Practice Address - Fax:202-545-0934
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide