Provider Demographics
NPI:1487237400
Name:MBONO, ANASTASIE
Entity type:Individual
Prefix:
First Name:ANASTASIE
Middle Name:
Last Name:MBONO
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 1:658 CHAPELGATE DR
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-2140
Mailing Address - Country:US
Mailing Address - Phone:301-806-2953
Mailing Address - Fax:
Practice Address - Street 1:207 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CHARLES TOWN
Practice Address - State:WV
Practice Address - Zip Code:25414-1531
Practice Address - Country:US
Practice Address - Phone:304-724-2135
Practice Address - Fax:304-724-2137
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV251E00000X
MD251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLP298832OtherNURSING LICENSE