Provider Demographics
NPI:1093149957
Name:IDEHEN, NATHANIEL M
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:M
Last Name:IDEHEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 SOUTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-1848
Mailing Address - Country:US
Mailing Address - Phone:301-493-4200
Mailing Address - Fax:301-493-6209
Practice Address - Street 1:6040 SOUTHPORT DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814-1848
Practice Address - Country:US
Practice Address - Phone:301-493-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR195044163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse