Healthcare Provider Details

I. General information

NPI: 1518457910
Provider Name (Legal Business Name): MAMADOU SALIEU JALLOW RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 10/08/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 S HIGH ST
COLUMBUS OH
43207-1045
US

IV. Provider business mailing address

4236 CODE PL
COLUMBUS OH
43207-8623
US

V. Phone/Fax

Practice location:
  • Phone: 614-445-8131
  • Fax:
Mailing address:
  • Phone: 614-327-2126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN.CNP.0029755
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.444588
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: