Provider Demographics
NPI:1578823704
Name:TALECH DJOENDIA, LARISSA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:TALECH DJOENDIA
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 1:72 GALVESTON ST SW
Mailing Address - Street 2:APT T1
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1982
Mailing Address - Country:US
Mailing Address - Phone:202-529-6510
Mailing Address - Fax:
Practice Address - Street 1:72 GALVESTON ST SW
Practice Address - Street 2:APT T1
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1982
Practice Address - Country:US
Practice Address - Phone:202-529-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide