Provider Demographics
NPI:1609411305
Name:TAH, JUDITH AMUTENG
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:AMUTENG
Last Name:TAH
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 1:13822 NORTHCREST RD
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2447
Mailing Address - Country:US
Mailing Address - Phone:301-326-7858
Mailing Address - Fax:540-683-8988
Practice Address - Street 1:13822 NORTHCREST RD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2447
Practice Address - Country:US
Practice Address - Phone:301-326-7858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-17
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD5000389048171WV0202X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171WV0202XOther Service ProvidersContractorVehicle Modifications