Provider Demographics
NPI:1063999894
Name:ADDY, TETTEH
Entity type:Individual
Prefix:
First Name:TETTEH
Middle Name:
Last Name:ADDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13081 CAROLYN FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-5621
Mailing Address - Country:US
Mailing Address - Phone:757-268-9992
Mailing Address - Fax:
Practice Address - Street 1:13081 CAROLYN FOREST DR
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5621
Practice Address - Country:US
Practice Address - Phone:757-268-9992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA10747373343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)