Provider Demographics
NPI:1134598055
Name:TANIFORM, AYAH MUMAH (NP)
Entity type:Individual
Prefix:
First Name:AYAH
Middle Name:MUMAH
Last Name:TANIFORM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HONORINE
Other - Middle Name:AYAH
Other - Last Name:MUMAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3499 FORT MEADE RD APT 2
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10600 MELWOOD CHAPEL LN
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-2960
Practice Address - Country:US
Practice Address - Phone:240-646-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR190176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily