Provider Demographics
NPI:1649914474
Name:QUEEN, DARUAN MARCELLUS
Entity type:Individual
Prefix:
First Name:DARUAN
Middle Name:MARCELLUS
Last Name:QUEEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6142 SURREY SQUARE LN APT 202
Mailing Address - Street 2:
Mailing Address - City:DISTRICT HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20747-2920
Mailing Address - Country:US
Mailing Address - Phone:202-910-9521
Mailing Address - Fax:
Practice Address - Street 1:602 AVA CIR NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2306
Practice Address - Country:US
Practice Address - Phone:202-701-7707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC521532BMedicaid