Provider Demographics
NPI:1548808447
Name:WEAH, GRACIOUS (CNA-DT)
Entity type:Individual
Prefix:
First Name:GRACIOUS
Middle Name:
Last Name:WEAH
Suffix:
Gender:F
Credentials:CNA-DT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8603 GRAY FOX RD APT 203
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5145
Mailing Address - Country:US
Mailing Address - Phone:443-565-2619
Mailing Address - Fax:
Practice Address - Street 1:8603 GRAY FOX RD APT 203
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-5145
Practice Address - Country:US
Practice Address - Phone:443-565-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
843936784OtherHOME HEALTHCARE