Provider Demographics
NPI:1629830302
Name:TATAH, MIRENE
Entity Type:Individual
Prefix:
First Name:MIRENE
Middle Name:
Last Name:TATAH
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 1:8551 GREENBELT RD APT 103
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2335
Mailing Address - Country:US
Mailing Address - Phone:240-797-6562
Mailing Address - Fax:
Practice Address - Street 1:8551 GREENBELT RD APT 103
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2335
Practice Address - Country:US
Practice Address - Phone:240-797-6562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MDRSA-02033251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator