Provider Demographics
NPI:1174622989
Name:TARAWALI, FATMATA TITY (APRN)
Entity type:Individual
Prefix:MRS
First Name:FATMATA
Middle Name:TITY
Last Name:TARAWALI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6903 GREENVALE PKWY
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-1538
Mailing Address - Country:US
Mailing Address - Phone:301-772-0957
Mailing Address - Fax:301-772-1628
Practice Address - Street 1:4390 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6068
Practice Address - Country:US
Practice Address - Phone:410-203-1700
Practice Address - Fax:410-203-1026
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN50629363L00000X
MDR091956363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC029880400Medicaid
MD082NR615Medicare UPIN
DC095020Medicare ID - Type UnspecifiedPROVIDER NUMBER