Provider Demographics
NPI:1710793021
Name:ETIENNE, ROUSSAN JUNIOR (PCA)
Entity type:Individual
Prefix:
First Name:ROUSSAN
Middle Name:JUNIOR
Last Name:ETIENNE
Suffix:
Gender:M
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 18TH ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2418
Mailing Address - Country:US
Mailing Address - Phone:202-938-5622
Mailing Address - Fax:
Practice Address - Street 1:101 G ST SW APT A109
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20024-4305
Practice Address - Country:US
Practice Address - Phone:202-599-2554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-10
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant