Provider Demographics
NPI:1477289395
Name:AMUKU, CLINTON S
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:S
Last Name:AMUKU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BUCHANAN ST APT 202
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-1122
Mailing Address - Country:US
Mailing Address - Phone:240-736-0103
Mailing Address - Fax:
Practice Address - Street 1:3333 BUCHANAN ST APT 202
Practice Address - Street 2:
Practice Address - City:MOUNT RAINIER
Practice Address - State:MD
Practice Address - Zip Code:20712-1122
Practice Address - Country:US
Practice Address - Phone:240-736-0103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCHHA200001958Medicaid