Provider Demographics
NPI:1104396712
Name:LASSA, PIDENAM
Entity Type:Individual
Prefix:
First Name:PIDENAM
Middle Name:
Last Name:LASSA
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 1:554 SHEPHERD ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-5913
Mailing Address - Country:US
Mailing Address - Phone:202-867-7383
Mailing Address - Fax:
Practice Address - Street 1:554 SHEPHERD ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5913
Practice Address - Country:US
Practice Address - Phone:202-867-7383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14157374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide