Provider Demographics
NPI:1700613072
Name:COLE, CLINTON
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:COLE
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 1:10731 CASTLETON WAY
Mailing Address - Street 2:
Mailing Address - City:UPR MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1338
Mailing Address - Country:US
Mailing Address - Phone:240-990-1806
Mailing Address - Fax:
Practice Address - Street 1:1430 L ST SE APT 105
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-3232
Practice Address - Country:US
Practice Address - Phone:202-725-8462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant