Provider Demographics
NPI:1053972521
Name:FONKEM, RAYMOND ZAH
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:ZAH
Last Name:FONKEM
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 1:2314 BRIGHTSEAT RD APT 002
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3554
Mailing Address - Country:US
Mailing Address - Phone:240-918-2235
Mailing Address - Fax:
Practice Address - Street 1:2314 BRIGHTSEAT RD APT 002
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-3554
Practice Address - Country:US
Practice Address - Phone:240-918-2235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14489374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide