Healthcare Provider Details

I. General information

NPI: 1407415938
Provider Name (Legal Business Name): BINTOU G KABA-HENDERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2019
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 WILDWOOD ST
LORTON VA
22079-1818
US

IV. Provider business mailing address

9200 WILDWOOD ST
LORTON VA
22079-1818
US

V. Phone/Fax

Practice location:
  • Phone: 571-358-8318
  • Fax: 571-358-8318
Mailing address:
  • Phone: 571-358-8318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024177658
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: