Provider Demographics
NPI:1144902271
Name:BUNN, KISHA TERRELL
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:TERRELL
Last Name:BUNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KISHA
Other - Middle Name:TERRELL
Other - Last Name:BUNN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:12903 GLYNIS RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4546
Mailing Address - Country:US
Mailing Address - Phone:202-386-4250
Mailing Address - Fax:
Practice Address - Street 1:12903 GLYNIS RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-4546
Practice Address - Country:US
Practice Address - Phone:202-386-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA374U00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide