Healthcare Provider Details

I. General information

NPI: 1225865975
Provider Name (Legal Business Name): MS. NOUDJAL GAMOUGOUN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11941 BOURNEFIELD WAY
SILVER SPRING MD
20904-7821
US

IV. Provider business mailing address

5431 TILTED STONE
COLUMBIA MD
21045-2429
US

V. Phone/Fax

Practice location:
  • Phone: 240-503-6672
  • Fax:
Mailing address:
  • Phone: 505-702-5880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: