Provider Demographics
NPI:1750754297
Name:DJAMBOU WASSI, IVIE SORELLE
Entity type:Individual
Prefix:
First Name:IVIE
Middle Name:SORELLE
Last Name:DJAMBOU WASSI
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 1:1612 BRIGHTSEAT RD
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3764
Mailing Address - Country:US
Mailing Address - Phone:240-764-9154
Mailing Address - Fax:
Practice Address - Street 1:3500 18TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2738
Practice Address - Country:US
Practice Address - Phone:202-529-6510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11487374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide