Provider Demographics
NPI:1174136444
Name:MIMS, MELISA TANISHA
Entity type:Individual
Prefix:
First Name:MELISA
Middle Name:TANISHA
Last Name:MIMS
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 1:1070 MOUNT OLIVET RD NE APT C42
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-2233
Mailing Address - Country:US
Mailing Address - Phone:202-421-4553
Mailing Address - Fax:
Practice Address - Street 1:2611 SOUTH CLARK STREET
Practice Address - Street 2:SUITE 700
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22201
Practice Address - Country:US
Practice Address - Phone:844-381-4432
Practice Address - Fax:877-763-2165
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC03747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant