Healthcare Provider Details

I. General information

NPI: 1750077541
Provider Name (Legal Business Name): PATRICIAMARIE MGBODILE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 FAIRFAX AVE
NORFOLK VA
23507-1914
US

IV. Provider business mailing address

PO BOX 1980
NORFOLK VA
23501-1980
US

V. Phone/Fax

Practice location:
  • Phone: 575-466-5123
  • Fax:
Mailing address:
  • Phone:
  • 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: