Provider Demographics
NPI:1205433679
Name:TANU, ECIA MIRIAN (CNA)
Entity type:Individual
Prefix:
First Name:ECIA
Middle Name:MIRIAN
Last Name:TANU
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 WALLINGFORD CT
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3183
Mailing Address - Country:US
Mailing Address - Phone:240-423-6422
Mailing Address - Fax:
Practice Address - Street 1:2600 WALLINGFORD CT
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-3183
Practice Address - Country:US
Practice Address - Phone:240-423-6422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00180500163WH0200X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA00180500OtherDRIVERS LICENSE