Provider Demographics
NPI:1336639475
Name:MASSING EPSE MOFFO, OLIVIA (PCA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MASSING EPSE MOFFO
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 METZEROTT RD APT 57
Mailing Address - Street 2:
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783-5176
Mailing Address - Country:US
Mailing Address - Phone:301-273-4364
Mailing Address - Fax:
Practice Address - Street 1:1814 METZEROTT RD APT 57
Practice Address - Street 2:
Practice Address - City:ADELPHI
Practice Address - State:MD
Practice Address - Zip Code:20783-5176
Practice Address - Country:US
Practice Address - Phone:240-476-5435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide