Provider Demographics
NPI:1770146789
Name:ENJEH MARY, CONCILIA DABA
Entity type:Individual
Prefix:
First Name:CONCILIA DABA
Middle Name:
Last Name:ENJEH MARY
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 1:5309 RIVERDALE RD APT 402
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737-2232
Mailing Address - Country:US
Mailing Address - Phone:301-792-0783
Mailing Address - Fax:
Practice Address - Street 1:5309 RIVERDALE RD APT 402
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-2232
Practice Address - Country:US
Practice Address - Phone:240-495-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14380374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCHHA14380Medicaid