Provider Demographics
NPI:1871028654
Name:KEKIA EPSE TANGUFOR, GRACE A
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:A
Last Name:KEKIA EPSE TANGUFOR
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 1:9741 GOOD LUCK RD
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3320
Mailing Address - Country:US
Mailing Address - Phone:240-543-2385
Mailing Address - Fax:
Practice Address - Street 1:9741 GOOD LUCK RD APT 5
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3320
Practice Address - Country:US
Practice Address - Phone:240-543-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide