Provider Demographics
NPI:1952296279
Name:FOSE, CLETUS
Entity type:Individual
Prefix:
First Name:CLETUS
Middle Name:
Last Name:FOSE
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 1:11212 CHERRY HILL RD APT 104
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-3817
Mailing Address - Country:US
Mailing Address - Phone:603-724-1882
Mailing Address - Fax:603-724-1882
Practice Address - Street 1:702 15TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-4508
Practice Address - Country:US
Practice Address - Phone:202-833-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1043935172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker