=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891299566
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA NGUM TABUFOR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2018
-----------------------------------------------------
Last Update Date | 03/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3811 MINNESOTA AVE NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20019-2660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-239-2666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7751 RIVERDALE RD APT 203
-----------------------------------------------------
City | NEW CARROLLTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20784-3916
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-484-0062
-----------------------------------------------------
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 | HHA13537
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------