Healthcare Provider Details

I. General information

NPI: 1922668250
Provider Name (Legal Business Name): ITA MBU UH FRU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 06/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 18TH ST NE
WASHINGTON DC
20018-2738
US

IV. Provider business mailing address

13916 CASTLE BLVD APT T2
SILVER SPRING MD
20904-4952
US

V. Phone/Fax

Practice location:
  • Phone: 202-529-6510
  • Fax: 202-529-6570
Mailing address:
  • Phone: 202-386-0561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA14509
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: