Healthcare Provider Details

I. General information

NPI: 1134477664
Provider Name (Legal Business Name): ALBERT LEGRAND SOMO DZATI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14304 DRIFTWOOD RD
BOWIE MD
20721-3044
US

IV. Provider business mailing address

14304 DRIFTWOOD RD
BOWIE MD
20721-3044
US

V. Phone/Fax

Practice location:
  • Phone: 240-260-3951
  • Fax:
Mailing address:
  • Phone: 202-904-4216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR218461
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: