Healthcare Provider Details

I. General information

NPI: 1184452310
Provider Name (Legal Business Name): MS. MAMBO AWAHMUKALAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10507 WHARFDALE PL
GAINESVILLE VA
20155-4871
US

IV. Provider business mailing address

10507 WHARFDALE PL
GAINESVILLE VA
20155-4871
US

V. Phone/Fax

Practice location:
  • Phone: 571-261-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number0001267803
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: