Provider Demographics
NPI:1184419582
Name:NYAM, DERICK TANTO
Entity type:Individual
Prefix:
First Name:DERICK TANTO
Middle Name:
Last Name:NYAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 KETTERING DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1522
Mailing Address - Country:US
Mailing Address - Phone:301-531-0887
Mailing Address - Fax:
Practice Address - Street 1:423 KETTERING DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-1522
Practice Address - Country:US
Practice Address - Phone:301-531-0887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC200004455374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide