Provider Demographics
NPI:1801155403
Name:AWASUM, MIRABELL TIFUH
Entity type:Individual
Prefix:MISS
First Name:MIRABELL
Middle Name:TIFUH
Last Name:AWASUM
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 1:6906 22ND PL
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2802
Mailing Address - Country:US
Mailing Address - Phone:240-351-9518
Mailing Address - Fax:
Practice Address - Street 1:6906 22ND PL
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-2802
Practice Address - Country:US
Practice Address - Phone:240-351-9518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-16
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA- 250603793883374U00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide