Healthcare Provider Details

I. General information

NPI: 1447511167
Provider Name (Legal Business Name): MRS. FRIDA MAMBO FRU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 DUPONT CIR NW
WASHINGTON DC
20036-1108
US

IV. Provider business mailing address

17505 MADRILLON WAY
ACCOKEEK MD
20607-3457
US

V. Phone/Fax

Practice location:
  • Phone: 301-273-5103
  • Fax:
Mailing address:
  • Phone: 301-273-5103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR202495
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN1032808
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: