Provider Demographics
NPI:1417582297
Name:CARTER, DAMIAH MONAE
Entity Type:Individual
Prefix:
First Name:DAMIAH
Middle Name:MONAE
Last Name:CARTER
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 1:25854 IRIS AVE UNIT C
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-2935
Mailing Address - Country:US
Mailing Address - Phone:951-210-4214
Mailing Address - Fax:
Practice Address - Street 1:25854 IRIS AVE UNIT C
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-2935
Practice Address - Country:US
Practice Address - Phone:951-210-4214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF13377803747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5302012Medicaid
CA2104214Medicaid