Provider Demographics
NPI:1376118182
Name:AHENKORAH, AUGUSTINE
Entity Type:Individual
Prefix:
First Name:AUGUSTINE
Middle Name:
Last Name:AHENKORAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 SHIRLEY GATE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5518
Mailing Address - Country:US
Mailing Address - Phone:170-205-9452
Mailing Address - Fax:
Practice Address - Street 1:4410 SHIRLEY GATE RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-5518
Practice Address - Country:US
Practice Address - Phone:703-489-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001271003163W00000X
VA2023059114363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse