Provider Demographics
NPI:1679056642
Name:BAH, DJENABOU
Entity type:Individual
Prefix:MRS
First Name:DJENABOU
Middle Name:
Last Name:BAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DJENABOU
Other - Middle Name:
Other - Last Name:DIALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2024 BENEDICT AVE APT 4D
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4427
Mailing Address - Country:US
Mailing Address - Phone:646-217-8492
Mailing Address - Fax:
Practice Address - Street 1:391 E 149TH ST RM 417
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3907
Practice Address - Country:US
Practice Address - Phone:646-702-6965
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYK5Q8B9A246RP1900X
NY9190L001374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPU90872WMedicaid