Provider Demographics
NPI:1700382165
Name:ENDAM EPSE UKU, CALISTA TETUH
Entity Type:Individual
Prefix:
First Name:CALISTA
Middle Name:TETUH
Last Name:ENDAM EPSE UKU
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 1:5718 CYPRESS CREEK DR APT 103
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-1832
Mailing Address - Country:US
Mailing Address - Phone:240-495-9137
Mailing Address - Fax:
Practice Address - Street 1:5718 CYPRESS CREEK DR APT 103
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-1832
Practice Address - Country:US
Practice Address - Phone:240-495-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13249374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide