Provider Demographics
NPI:1558864108
Name:ATUNGTANG, JERSIRA S
Entity Type:Individual
Prefix:
First Name:JERSIRA
Middle Name:S
Last Name:ATUNGTANG
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 1:5103 WHITTINGTON LN
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6009
Mailing Address - Country:US
Mailing Address - Phone:240-898-8964
Mailing Address - Fax:
Practice Address - Street 1:5103 WHITTINGTON LN
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-6009
Practice Address - Country:US
Practice Address - Phone:240-898-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA10975374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide