Provider Demographics
NPI:1801504790
Name:FORTUNE, MAGUIEM TAKO (LPN)
Entity type:Individual
Prefix:
First Name:MAGUIEM
Middle Name:TAKO
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9741 GOOD LUCK RD APT 11
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3320
Mailing Address - Country:US
Mailing Address - Phone:240-590-4177
Mailing Address - Fax:
Practice Address - Street 1:1615 KENILWORTH AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2010
Practice Address - Country:US
Practice Address - Phone:202-588-8036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP56302164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse