Provider Demographics
NPI:1407374382
Name:MKOROMBINDO, MERCY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MERCY
Middle Name:
Last Name:MKOROMBINDO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 MIRA MONTE CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-5041
Mailing Address - Country:US
Mailing Address - Phone:909-478-5909
Mailing Address - Fax:
Practice Address - Street 1:14121 PARKE LONG CT STE 201
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:855-247-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006003363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily