Healthcare Provider Details

I. General information

NPI: 1881132439
Provider Name (Legal Business Name): MAHELET MAMO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2017
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WILSON BLVD
ARLINGTON VA
22209-2211
US

IV. Provider business mailing address

1101 WILSON BLVD
ARLINGTON VA
22209-2211
US

V. Phone/Fax

Practice location:
  • Phone: 703-338-9490
  • Fax:
Mailing address:
  • Phone: 703-338-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024174476
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: