Provider Demographics
NPI:1295165462
Name:MUTAGHA EPSE TEZOCK, CHANTALE
Entity type:Individual
Prefix:
First Name:CHANTALE
Middle Name:
Last Name:MUTAGHA EPSE TEZOCK
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 1:7513 BUCHANAN ST APT 127
Mailing Address - Street 2:
Mailing Address - City:LANDOVER HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20784-6310
Mailing Address - Country:US
Mailing Address - Phone:240-696-9535
Mailing Address - Fax:
Practice Address - Street 1:7513 BUCHANAN ST APT 127
Practice Address - Street 2:
Practice Address - City:LANDOVER HILLS
Practice Address - State:MD
Practice Address - Zip Code:20784-6310
Practice Address - Country:US
Practice Address - Phone:240-696-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide