Provider Demographics
NPI:1023430337
Name:DIMBECK, ETIENNE
Entity type:Individual
Prefix:
First Name:ETIENNE
Middle Name:
Last Name:DIMBECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1626
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-0626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3671 AUTUMN GLENN CIRCLE
Practice Address - Street 2:
Practice Address - City:BOTURNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866
Practice Address - Country:US
Practice Address - Phone:443-813-8209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA9092374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide