Provider Demographics
NPI:1093149726
Name:TSUALA MAUFOR, MARIANNE
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:TSUALA MAUFOR
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 1:1101 NIMMO PKWY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-7730
Mailing Address - Country:US
Mailing Address - Phone:757-427-1655
Mailing Address - Fax:
Practice Address - Street 1:1101 NIMMO PKWY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-7730
Practice Address - Country:US
Practice Address - Phone:757-427-1655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27666183500000X
374U00000X
VA0202219314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No374U00000XNursing Service Related ProvidersHome Health Aide