=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396553780
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMUTALLAH ABDUSSALAAM AGNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2024
-----------------------------------------------------
Last Update Date | 12/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3640 HIGH ST STE 1E
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23707-3213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-399-2639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3640 HIGH ST STE 1E
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23707-3213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-399-2639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 0024192072
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------