Provider Demographics
NPI:1700483310
Name:WUTANG, GENEVIVE
Entity Type:Individual
Prefix:MRS
First Name:GENEVIVE
Middle Name:
Last Name:WUTANG
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 1:6103 ERIKA PL
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9220
Mailing Address - Country:US
Mailing Address - Phone:240-828-9004
Mailing Address - Fax:
Practice Address - Street 1:12423 RONALD BEALL RD
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5686
Practice Address - Country:US
Practice Address - Phone:240-828-9004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No374U00000XNursing Service Related ProvidersHome Health Aide