Provider Demographics
NPI:1275224677
Name:BANGURA, ALIMATU MARY
Entity Type:Individual
Prefix:
First Name:ALIMATU
Middle Name:MARY
Last Name:BANGURA
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 1:7700 LITTLE RIVER TPKE STE 305
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2406
Mailing Address - Country:US
Mailing Address - Phone:240-618-9820
Mailing Address - Fax:
Practice Address - Street 1:7700 LITTLE RIVER TPKE STE 305
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2406
Practice Address - Country:US
Practice Address - Phone:240-618-9820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMEDICAIDMedicaid
VA1699725143OtherMODIVCARE