Provider Demographics
NPI:1730996703
Name:MBAH, GWENDOLINE TICHA
Entity type:Individual
Prefix:
First Name:GWENDOLINE
Middle Name:TICHA
Last Name:MBAH
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 1:5451 85TH AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4527
Mailing Address - Country:US
Mailing Address - Phone:240-886-4064
Mailing Address - Fax:
Practice Address - Street 1:5451 85TH AVE APT 102
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4527
Practice Address - Country:US
Practice Address - Phone:240-886-4064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide