Provider Demographics
NPI:1689028441
Name:KETCHIAMEN, STELLA DELANGE
Entity Type:Individual
Prefix:
First Name:STELLA DELANGE
Middle Name:
Last Name:KETCHIAMEN
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 1:2509 ARUNDEL RD APT 6
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-2209
Mailing Address - Country:US
Mailing Address - Phone:202-556-7058
Mailing Address - Fax:
Practice Address - Street 1:2509 ARUNDEL RD APT 6
Practice Address - Street 2:
Practice Address - City:MOUNT RAINIER
Practice Address - State:MD
Practice Address - Zip Code:20712-2209
Practice Address - Country:US
Practice Address - Phone:202-556-7058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11994374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1982Medicaid
DC1982198219Medicare NSC
DC1234567890Medicare PIN
DC1234567Medicare UPIN
DC198212345678909Medicare Oscar/Certification
DC12345Medicare PIN