Provider Demographics
NPI:1518569938
Name:CARSON, MALITA LYNN
Entity Type:Individual
Prefix:
First Name:MALITA
Middle Name:LYNN
Last Name:CARSON
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 1:419 W ST NE # 304
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1249
Mailing Address - Country:US
Mailing Address - Phone:240-988-8345
Mailing Address - Fax:
Practice Address - Street 1:419 W ST NE # 304
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1249
Practice Address - Country:US
Practice Address - Phone:240-988-8345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC2556487Medicaid