MEDICARE: MARITA ATEHAKOH FORMIN NP

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	364SP0810X	Child & Family Psychiatric/Mental Health Clinical Nurse Specialist	R249853	MD

General Provider Information

NPI Number	:	1568827855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARITA ATEHAKOH FORMIN NP

Provider Business Mailing Address
First Line	:	7375 EXECUTIVE PL STE 200
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-6234
Country	:	US
Telephone Number	:	202-940-2022
Fax Number	:

Provider Business Practice Location Address
First Line	:	7375 EXECUTIVE PL
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-2278
Country	:	US
Telephone Number	:	202-940-2022
Fax Number	:

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

Provider Enumeration Date	:	12/31/2015
Last Update Date	:	03/02/2026

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