Provider Demographics
NPI:1801363213
Name:TANTOH MONDO, VIVIAN
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:TANTOH MONDO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:VIVIAN
Other - Middle Name:
Other - Last Name:TANTOH MONDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7452 BALTIMORE ANNAPOLIS BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3547
Mailing Address - Country:US
Mailing Address - Phone:443-209-7100
Mailing Address - Fax:
Practice Address - Street 1:7452 BALTIMORE ANNAPOLIS BLVD # 200
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3547
Practice Address - Country:US
Practice Address - Phone:443-209-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX929987363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty