Provider Demographics
NPI:1457871477
Name:WAN, ADJO HOLASE
Entity Type:Individual
Prefix:
First Name:ADJO
Middle Name:HOLASE
Last Name:WAN
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 1:9727 MOUNT PISGAH RD APT 512
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-2010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9727 MOUNT PISGAH RD APT 512
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-2010
Practice Address - Country:US
Practice Address - Phone:240-641-2954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-21
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
DCHHA12802374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator