Healthcare Provider Details

I. General information

NPI: 1407633423
Provider Name (Legal Business Name): KALILOU DJOBO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S KING ST
SHEPHERDSTOWN WV
25443-7000
US

IV. Provider business mailing address

301 S KING ST
SHEPHERDSTOWN WV
25443-7000
US

V. Phone/Fax

Practice location:
  • Phone: 304-876-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR198617
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: