Provider Demographics
NPI:1861753428
Name:MBANWEI, SHELLEY KENNETH
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:KENNETH
Last Name:MBANWEI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:KENNETH
Other - Last Name:MBANWEI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7702 QUAINT CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4316
Mailing Address - Country:US
Mailing Address - Phone:202-629-8674
Mailing Address - Fax:
Practice Address - Street 1:3300 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2408
Practice Address - Country:US
Practice Address - Phone:202-878-6626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 171M00000X, 251S00000X
DC140636374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No251S00000XAgenciesCommunity/Behavioral Health
No374U00000XNursing Service Related ProvidersHome Health Aide