Healthcare Provider Details

I. General information

NPI: 1487143608
Provider Name (Legal Business Name): FATIMATA KOROMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3953 ELITE ST
BOWIE MD
20716
US

IV. Provider business mailing address

3953 ELITE ST
BOWIE MD
20716-3370
US

V. Phone/Fax

Practice location:
  • Phone: 240-264-7387
  • Fax:
Mailing address:
  • Phone: 240-264-7387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberHHA12133
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA12133
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: