Provider Demographics
NPI:1326500976
Name:MARIOGHAE, ADETUTU
Entity Type:Individual
Prefix:MRS
First Name:ADETUTU
Middle Name:
Last Name:MARIOGHAE
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 1:12783 SIDNEY WAY
Mailing Address - Street 2:
Mailing Address - City:LAKE RIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-7611
Mailing Address - Country:US
Mailing Address - Phone:571-332-9032
Mailing Address - Fax:
Practice Address - Street 1:12783 SIDNEY WAY
Practice Address - Street 2:
Practice Address - City:LAKE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-7611
Practice Address - Country:US
Practice Address - Phone:571-332-9032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024176630363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024176630OtherCOMMONWEALTH OF VIRGINIA DEPARTMENT OF HEALTH PROFESSION