Provider Demographics
NPI:1740754068
Name:TAH, MIRABEL SUH
Entity Type:Individual
Prefix:
First Name:MIRABEL
Middle Name:SUH
Last Name:TAH
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 1:5822 MENTANA ST
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-3505
Mailing Address - Country:US
Mailing Address - Phone:240-470-2162
Mailing Address - Fax:
Practice Address - Street 1:5822 MENTANA ST
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-3505
Practice Address - Country:US
Practice Address - Phone:240-470-2162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14197374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide