Provider Demographics
NPI:1548528599
Name:TAKANG, EVELINE
Entity type:Individual
Prefix:
First Name:EVELINE
Middle Name:
Last Name:TAKANG
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 1:12904 NORTHAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-6332
Mailing Address - Country:US
Mailing Address - Phone:240-264-9698
Mailing Address - Fax:
Practice Address - Street 1:12904 NORTHAMPTON DR
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-6332
Practice Address - Country:US
Practice Address - Phone:240-264-9698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2017-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR167174363LG0600X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program