Provider Demographics
NPI:1114575347
Name:HERNDON, JOETTA ITIVIS
Entity Type:Individual
Prefix:
First Name:JOETTA
Middle Name:ITIVIS
Last Name:HERNDON
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 1:2704 WADE RD SE APT 301
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5951
Mailing Address - Country:US
Mailing Address - Phone:202-704-7886
Mailing Address - Fax:
Practice Address - Street 1:3348 BLAINE ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-1327
Practice Address - Country:US
Practice Address - Phone:202-399-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide