Provider Demographics
NPI:1760995021
Name:TAKHA, SIYAMI EGBASE (CRNP)
Entity Type:Individual
Prefix:MS
First Name:SIYAMI
Middle Name:EGBASE
Last Name:TAKHA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30007 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE HALL
Mailing Address - State:MD
Mailing Address - Zip Code:20622-3101
Mailing Address - Country:US
Mailing Address - Phone:301-997-1300
Mailing Address - Fax:
Practice Address - Street 1:12070 OLD LINE CTR STE 209
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2567
Practice Address - Country:US
Practice Address - Phone:202-705-4133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194882363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care