Provider Demographics
NPI:1649720038
Name:RICHARDSON, GLORIA
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:RICHARDSON
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 1:6417 KANSAS AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-2105
Mailing Address - Country:US
Mailing Address - Phone:202-629-2169
Mailing Address - Fax:
Practice Address - Street 1:6417 KANSAS AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-2105
Practice Address - Country:US
Practice Address - Phone:202-629-2169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN68274163W00000X
DCALR0027310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No163W00000XNursing Service ProvidersRegistered Nurse