Healthcare Provider Details

I. General information

NPI: 1710375985
Provider Name (Legal Business Name): TARQUEEN UDOSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2014
Last Update Date: 12/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 9TH ST NW
WASHINGTON DC
20001-4107
US

IV. Provider business mailing address

7123 LORY LN
LANHAM MD
20706-1113
US

V. Phone/Fax

Practice location:
  • Phone: 240-460-7060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA9552
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: