Healthcare Provider Details

I. General information

NPI: 1467372987
Provider Name (Legal Business Name): TYASIA CHANTENIYA MOULTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2026
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19429 BRASSIE PL APT 301
MONTGOMERY VILLAGE MD
20886-1938
US

IV. Provider business mailing address

19429 BRASSIE PL APT 301
MONTGOMERY VILLAGE MD
20886-1938
US

V. Phone/Fax

Practice location:
  • Phone: 240-789-8465
  • Fax:
Mailing address:
  • Phone: 240-789-8465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: