Provider Demographics
NPI:1942040605
Name:WANDJA EPSE WAM, LILIANE
Entity type:Individual
Prefix:
First Name:LILIANE
Middle Name:
Last Name:WANDJA EPSE WAM
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 1:9252 PINEY BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-2835
Mailing Address - Country:US
Mailing Address - Phone:240-230-5425
Mailing Address - Fax:
Practice Address - Street 1:506 CHILLUM RD
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3314
Practice Address - Country:US
Practice Address - Phone:240-230-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide