=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982236774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ET HEALTHCARE FOUNDATION,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2020
-----------------------------------------------------
Last Update Date | 02/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7231 HANOVER PKWY STE A
-----------------------------------------------------
City | GREENBELT
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20770-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-982-7898
-----------------------------------------------------
Fax | 301-982-2588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7231 HANOVER PKWY STE A
-----------------------------------------------------
City | GREENBELT
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20770-2027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-982-7898
-----------------------------------------------------
Fax | 301-982-2588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ETA STEPHEN TATAW
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 301-982-7898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------