Provider Demographics
NPI:1154667772
Name:NGAWANA, JERRY FARH TITA
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:FARH TITA
Last Name:NGAWANA
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 1:2718 HAMLIN ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2533
Mailing Address - Country:US
Mailing Address - Phone:202-471-0856
Mailing Address - Fax:
Practice Address - Street 1:2312 RHODE ISLAND AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018
Practice Address - Country:US
Practice Address - Phone:202-635-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide