Provider Demographics
NPI:1447723556
Name:SOUVERAIN, WIDLINE
Entity type:Individual
Prefix:
First Name:WIDLINE
Middle Name:
Last Name:SOUVERAIN
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 1:3352 CHILLUM RD APT 302
Mailing Address - Street 2:
Mailing Address - City:MOUNT RAINIER
Mailing Address - State:MD
Mailing Address - Zip Code:20712-1139
Mailing Address - Country:US
Mailing Address - Phone:240-988-9488
Mailing Address - Fax:
Practice Address - Street 1:1753 A ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-1618
Practice Address - Country:US
Practice Address - Phone:301-775-6921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD913679417Medicaid