=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164064705
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GHISLAINE KENMEGNE DATOUO MOGO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2019
-----------------------------------------------------
Last Update Date | 10/15/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4130 HUNT PL NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20019-3565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-679-0620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9580 MUIRKIRK RD APT 101
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20708-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-705-1096
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN1028252
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------