Provider Demographics
NPI:1760968697
Name:TEBO, VELMA ENJIE
Entity Type:Individual
Prefix:
First Name:VELMA
Middle Name:ENJIE
Last Name:TEBO
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 1:1511 FRANKLIN ST NE APT 510
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2054
Mailing Address - Country:US
Mailing Address - Phone:202-390-6808
Mailing Address - Fax:
Practice Address - Street 1:1511 FRANKLIN ST NE APT 510
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018
Practice Address - Country:US
Practice Address - Phone:202-390-6808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA13866374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1700370236Medicaid