Provider Demographics
NPI:1174026462
Name:ANDERSON, TAWANNA
Entity type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
Last Name:ANDERSON
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 1:1108 KAYAK AVE
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-4043
Mailing Address - Country:US
Mailing Address - Phone:202-480-6444
Mailing Address - Fax:
Practice Address - Street 1:1108 KAYAK AVE
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-4043
Practice Address - Country:US
Practice Address - Phone:202-480-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide