Provider Demographics
NPI:1043706807
Name:TANYI ESANG EPSE MUKUM, THERESIA
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:
Last Name:TANYI ESANG EPSE MUKUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4509 DOCTOR BEANS LEGACY CIR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-6385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4509 DR BEANS LEGACY CIR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-6385
Practice Address - Country:US
Practice Address - Phone:240-467-1285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDHHA13786374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide