Provider Demographics
NPI:1497204606
Name:FUABA, SUSSANA
Entity Type:Individual
Prefix:
First Name:SUSSANA
Middle Name:
Last Name:FUABA
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 1:9110 MCHENRY LN
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-4158
Mailing Address - Country:US
Mailing Address - Phone:301-543-0484
Mailing Address - Fax:
Practice Address - Street 1:9110 MCHENRY LN
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-4158
Practice Address - Country:US
Practice Address - Phone:301-543-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA12425374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide