Healthcare Provider Details

I. General information

NPI: 1508548058
Provider Name (Legal Business Name): MISS MARIAMA DANIELA KOROMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

749 FARAWAY CT
BOWIE MD
20721-1825
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-8118
  • Fax:
Mailing address:
  • Phone: 240-938-8029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR220181
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: