Provider Demographics
NPI:1073231924
Name:DIALLO, FATOUMATA D
Entity Type:Individual
Prefix:
First Name:FATOUMATA
Middle Name:D
Last Name:DIALLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 MERCANTILE LN # 129-2
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5327
Mailing Address - Country:US
Mailing Address - Phone:301-272-1055
Mailing Address - Fax:301-272-1056
Practice Address - Street 1:1300 MERCANTILE LN # 129-2
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5327
Practice Address - Country:US
Practice Address - Phone:301-272-1055
Practice Address - Fax:301-272-1056
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR218923363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health