Provider Demographics
NPI:1295094878
Name:MOUTO, AGATHE EYOUM
Entity type:Individual
Prefix:
First Name:AGATHE
Middle Name:EYOUM
Last Name:MOUTO
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 1:7600 MAPLE AVE APT 1409
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-5556
Mailing Address - Country:US
Mailing Address - Phone:240-988-4154
Mailing Address - Fax:
Practice Address - Street 1:7600 MAPLE AVE APT 1409
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-5556
Practice Address - Country:US
Practice Address - Phone:240-988-4154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM-300034241252374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide