Provider Demographics
NPI:1154675007
Name:EVERETTE, MILLICENT DANIELLE
Entity Type:Individual
Prefix:
First Name:MILLICENT
Middle Name:DANIELLE
Last Name:EVERETTE
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 1:6109 SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-6532
Mailing Address - Country:US
Mailing Address - Phone:202-629-7104
Mailing Address - Fax:
Practice Address - Street 1:6109 SOUTHGATE DR
Practice Address - Street 2:
Practice Address - City:TEMPLE HILLS
Practice Address - State:MD
Practice Address - Zip Code:20748-6532
Practice Address - Country:US
Practice Address - Phone:202-629-7104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC70661977Medicaid