Provider Demographics
NPI:1821436288
Name:ATABONG, DERICK AMIN (HHA)
Entity Type:Individual
Prefix:MR
First Name:DERICK
Middle Name:AMIN
Last Name:ATABONG
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13125 LARCHDALE RD
Mailing Address - Street 2:APT 7
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708
Mailing Address - Country:US
Mailing Address - Phone:240-646-4085
Mailing Address - Fax:
Practice Address - Street 1:13125 LARCHDALE RD
Practice Address - Street 2:APT 7
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708
Practice Address - Country:US
Practice Address - Phone:240-646-4085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC4645374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide