Provider Demographics
NPI:1174117204
Name:DJEUTIO MAGO, HENRIETTE REINE
Entity type:Individual
Prefix:
First Name:HENRIETTE REINE
Middle Name:
Last Name:DJEUTIO MAGO
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 1:13117 CRUTCHFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-3212
Mailing Address - Country:US
Mailing Address - Phone:206-536-7239
Mailing Address - Fax:
Practice Address - Street 1:2811 PENN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3865
Practice Address - Country:US
Practice Address - Phone:202-894-6811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
DCNA0000812097376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide