Provider Demographics
NPI:1952079410
Name:CHI, CLARISSE KINE
Entity Type:Individual
Prefix:
First Name:CLARISSE
Middle Name:KINE
Last Name:CHI
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 1:8405 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4550
Mailing Address - Country:US
Mailing Address - Phone:240-593-1089
Mailing Address - Fax:
Practice Address - Street 1:3001 BLADENSBURG RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2235
Practice Address - Country:US
Practice Address - Phone:202-635-3577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1052716163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC236Medicaid