Provider Demographics
NPI:1164064705
Name:MOGO, GHISLAINE KENMEGNE DATOUO
Entity Type:Individual
Prefix:
First Name:GHISLAINE
Middle Name:KENMEGNE DATOUO
Last Name:MOGO
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 1:9580 MUIRKIRK RD APT 101
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2717
Mailing Address - Country:US
Mailing Address - Phone:240-705-1096
Mailing Address - Fax:
Practice Address - Street 1:4130 HUNT PL NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3565
Practice Address - Country:US
Practice Address - Phone:202-679-0620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1028252363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC000-000-000Medicaid