=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164936100
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHISOM LINDA AMAKOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2017
-----------------------------------------------------
Last Update Date | 11/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 MINN AVE NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20019-2660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-390-0824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5423 56TH AVE
-----------------------------------------------------
City | RIVERDALE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20737-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-390-0824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 13319
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------