Provider Demographics
NPI:1730909706
Name:ETIENDEM JUDE, NONGLEY N
Entity type:Individual
Prefix:
First Name:NONGLEY N
Middle Name:
Last Name:ETIENDEM JUDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14251 WILDERNESS LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-5654
Mailing Address - Country:US
Mailing Address - Phone:540-429-3077
Mailing Address - Fax:
Practice Address - Street 1:1039 BLADENSBURG RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-2922
Practice Address - Country:US
Practice Address - Phone:540-429-3077
Practice Address - Fax:703-205-2413
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator