=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467157552
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MERCY MBOLAH GHELI GANA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2023
-----------------------------------------------------
Last Update Date | 03/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6024 PURE SKY PL
-----------------------------------------------------
City | CLARKSVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21029-1238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-760-2236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17532 W WILLARD RD
-----------------------------------------------------
City | POOLESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20837-2088
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-706-6504
-----------------------------------------------------
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 | R231928
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------