Provider Demographics
NPI:1720840382
Name:SHU, ITA M
Entity type:Individual
Prefix:
First Name:ITA
Middle Name:M
Last Name:SHU
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 1:10712 MARIETTA ST
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9405
Mailing Address - Country:US
Mailing Address - Phone:240-510-4293
Mailing Address - Fax:
Practice Address - Street 1:10712 MARIETTA ST
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9405
Practice Address - Country:US
Practice Address - Phone:240-510-4293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA200003055374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide