Provider Demographics
NPI:1689295016
Name:NKETIAH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NKETIAH
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 1:19538 CRYSTAL ROCK DR APT 24
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-4932
Mailing Address - Country:US
Mailing Address - Phone:240-478-0949
Mailing Address - Fax:
Practice Address - Street 1:4320 CATHEDRAL AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-3561
Practice Address - Country:US
Practice Address - Phone:917-597-2457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
MDA00076519163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant