Provider Demographics
NPI:1073272910
Name:WAKE, ASNAKU BULTUME
Entity Type:Individual
Prefix:
First Name:ASNAKU
Middle Name:BULTUME
Last Name:WAKE
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 1:12500 STRATFORD GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1558
Mailing Address - Country:US
Mailing Address - Phone:301-792-6219
Mailing Address - Fax:410-946-2010
Practice Address - Street 1:12500 STRATFORD GARDEN DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1558
Practice Address - Country:US
Practice Address - Phone:301-792-6219
Practice Address - Fax:410-946-2010
Is Sole Proprietor?:No
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00188873376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide