Provider Demographics
NPI:1982965745
Name:FRUCTUOSO, YDAHINA
Entity Type:Individual
Prefix:
First Name:YDAHINA
Middle Name:
Last Name:FRUCTUOSO
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 1:1829 13TH ST NW
Mailing Address - Street 2:#304
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-4461
Mailing Address - Country:US
Mailing Address - Phone:202-609-3011
Mailing Address - Fax:
Practice Address - Street 1:1829 13TH ST NW
Practice Address - Street 2:#304
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009-4461
Practice Address - Country:US
Practice Address - Phone:202-609-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2763138374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide