Provider Demographics
NPI:1508635038
Name:EVERETT- GATLIN, TAKAHYA
Entity Type:Individual
Prefix:MS
First Name:TAKAHYA
Middle Name:
Last Name:EVERETT- GATLIN
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 1:4324 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-4922
Mailing Address - Country:US
Mailing Address - Phone:703-965-0739
Mailing Address - Fax:
Practice Address - Street 1:4324 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-4922
Practice Address - Country:US
Practice Address - Phone:703-965-0739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA8896253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care