Provider Demographics
NPI:1114798022
Name:TANIFORM MANJOH, BLANCH
Entity type:Individual
Prefix:
First Name:BLANCH
Middle Name:
Last Name:TANIFORM MANJOH
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 1:9505 HOBART ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5444
Mailing Address - Country:US
Mailing Address - Phone:901-453-5870
Mailing Address - Fax:
Practice Address - Street 1:9505 HOBART ST
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:MD
Practice Address - Zip Code:20774-5444
Practice Address - Country:US
Practice Address - Phone:901-453-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
DC171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide