Provider Demographics
NPI:1679939870
Name:FANDJO NUPA EPSE MANA, CLARISSE
Entity type:Individual
Prefix:
First Name:CLARISSE
Middle Name:
Last Name:FANDJO NUPA EPSE MANA
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 1:1070 COPPERSTONE CT # 712
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1144
Mailing Address - Country:US
Mailing Address - Phone:202-713-6735
Mailing Address - Fax:
Practice Address - Street 1:1070 COPPERSTONE CT # 712
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-1144
Practice Address - Country:US
Practice Address - Phone:202-713-6735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA11262374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide