Provider Demographics
NPI:1619759701
Name:FONYUY, TATA TERRENCE
Entity Type:Individual
Prefix:
First Name:TATA
Middle Name:TERRENCE
Last Name:FONYUY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7768 MANDAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2167
Mailing Address - Country:US
Mailing Address - Phone:240-581-2141
Mailing Address - Fax:
Practice Address - Street 1:7768 MANDAN RD
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2167
Practice Address - Country:US
Practice Address - Phone:443-400-9759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator