Provider Demographics
NPI:1174069041
Name:TIAHA PONDEM, MARIE LOUISE
Entity type:Individual
Prefix:
First Name:MARIE LOUISE
Middle Name:
Last Name:TIAHA PONDEM
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 1:2101 I ST NE APT 6
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3240
Mailing Address - Country:US
Mailing Address - Phone:202-702-4797
Mailing Address - Fax:
Practice Address - Street 1:7826 EASTERN AVE NW STE LL16
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1328
Practice Address - Country:US
Practice Address - Phone:202-723-1100
Practice Address - Fax:202-723-3271
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
DCHHA12553374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide