Healthcare Provider Details

I. General information

NPI: 1366083420
Provider Name (Legal Business Name): TANISHA NEKITA DEMESSA PHLEBOTOMIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13244 MUSICMASTER DR
SILVER SPRING MD
20904-6807
US

IV. Provider business mailing address

PO BOX 4341
SILVER SPRING MD
20914-4341
US

V. Phone/Fax

Practice location:
  • Phone: 240-676-6830
  • Fax:
Mailing address:
  • Phone: 240-676-6830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number224864
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: