Provider Demographics
NPI:1902165665
Name:ETTA, TABOT
Entity Type:Individual
Prefix:
First Name:TABOT
Middle Name:
Last Name:ETTA
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 1:8707 BARROW ST.
Mailing Address - Street 2:APT 4
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912
Mailing Address - Country:US
Mailing Address - Phone:240-706-3348
Mailing Address - Fax:202-241-2035
Practice Address - Street 1:8707 BARROW ST.
Practice Address - Street 2:APT 4
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912
Practice Address - Country:US
Practice Address - Phone:240-706-3348
Practice Address - Fax:202-241-2035
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDE300785002797374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide