Provider Demographics
NPI:1376136622
Name:COLE, KHADIJATU DENTON
Entity Type:Individual
Prefix:
First Name:KHADIJATU
Middle Name:DENTON
Last Name:COLE
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 1:14155 CASTLE BLVD APT 201
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-4759
Mailing Address - Country:US
Mailing Address - Phone:857-383-0028
Mailing Address - Fax:410-946-2010
Practice Address - Street 1:1615 KENILWORTH AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2010
Practice Address - Country:US
Practice Address - Phone:202-588-8036
Practice Address - Fax:410-946-2010
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00148664376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide