Provider Demographics
NPI:1104429356
Name:NTIYANKUNDIYE, DEO
Entity type:Individual
Prefix:MR
First Name:DEO
Middle Name:
Last Name:NTIYANKUNDIYE
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 1:10 RED OAK DR APT 2D
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2092
Mailing Address - Country:US
Mailing Address - Phone:207-332-0119
Mailing Address - Fax:
Practice Address - Street 1:6 SANCHO DRIVE
Practice Address - Street 2:
Practice Address - City:SACO,
Practice Address - State:ME
Practice Address - Zip Code:04072-0410
Practice Address - Country:US
Practice Address - Phone:207-332-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME101Y00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No101Y00000XBehavioral Health & Social Service ProvidersCounselor