Provider Demographics
NPI:1629653324
Name:WUVALLA, RENE
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:WUVALLA
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 1:212 SETTLERS WAY
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5770
Mailing Address - Country:US
Mailing Address - Phone:301-693-8876
Mailing Address - Fax:
Practice Address - Street 1:212 SETTLERS WAY
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5770
Practice Address - Country:US
Practice Address - Phone:301-693-8876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-14
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide