Provider Demographics
NPI:1730449547
Name:NGONGBA, LYDIA NGUM
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:NGUM
Last Name:NGONGBA
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 1:9014 BREEZEWOOD TER APT 104
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4012
Mailing Address - Country:US
Mailing Address - Phone:301-613-9095
Mailing Address - Fax:
Practice Address - Street 1:9014 BREEZEWOOD TER APT 104
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-4012
Practice Address - Country:US
Practice Address - Phone:301-613-9095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC21723168159179251E00000X
DCLPN1008892164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health