Basic Information
| Provider Information | |||||||||
| NPI: | 1528614245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TARAWALIE | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | WARRAH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | APRN- FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KAIKAI | ||||||||
| OtherFirstName: | ALUSINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 19703 EXECUTIVE PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208742639 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 19703 EXECUTIVE PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208742639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019466623 | ||||||||
| FaxNumber: | 3019461107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2019 | ||||||||
| LastUpdateDate: | 12/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R202403 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | R202403 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.