Provider Demographics
NPI:1417470519
Name:FANG, BERTINE
Entity Type:Individual
Prefix:
First Name:BERTINE
Middle Name:
Last Name:FANG
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 1:11449 CHERRY HILL RD APT 103
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3646
Mailing Address - Country:US
Mailing Address - Phone:240-360-3419
Mailing Address - Fax:
Practice Address - Street 1:11449 CHERRY HILL RD APT 103
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-3646
Practice Address - Country:US
Practice Address - Phone:240-360-3419
Practice Address - Fax:240-360-3419
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12904374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCHHA12904Medicaid