MEDICARE: JOSEPH FOTABONG ANCHE NYETMOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1407117260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH FOTABONG ANCHE NYETMOR

Provider Business Mailing Address
First Line	:	6733 NEW HAMPSHIRE AVE
Second Line	:	APT 404
City	:	TAKOMA PARK
State	:	MD
Zip	:	20912-4864
Country	:	US
Telephone Number	:	202-569-0062
Fax Number	:

Provider Business Practice Location Address
First Line	:	6733 NEW HAMPSHIRE AVE
Second Line	:	APT 404
City	:	TAKOMA PARK
State	:	MD
Zip	:	20912-4864
Country	:	US
Telephone Number	:	202-569-0062
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2012
Last Update Date	:	06/07/2012

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