Healthcare Provider Details

I. General information

NPI: 1477169936
Provider Name (Legal Business Name): MUTIAT O. POPOOLA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15518 KENNETT SQUARE WAY
BRANDYWINE MD
20613-6239
US

IV. Provider business mailing address

337 BRIGHTSEAT RD STE 201
HYATTSVILLE MD
20785-4736
US

V. Phone/Fax

Practice location:
  • Phone: 240-988-3779
  • Fax:
Mailing address:
  • Phone: 240-988-3779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR205702
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: