Healthcare Provider Details

I. General information

NPI: 1245591973
Provider Name (Legal Business Name): ANYINKENG LYDIA TAZI REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12003 PISCATAWAY RD
CLINTON MD
20735-1168
US

IV. Provider business mailing address

12003 PISCATAWAY RD
CLINTON MD
20735-1168
US

V. Phone/Fax

Practice location:
  • Phone: 240-691-6835
  • Fax:
Mailing address:
  • Phone: 240-691-6835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR208066
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1031555
License Number StateDC
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: