Provider Demographics
NPI:1417606724
Name:MAMO, ANDRINA VERONICA
Entity Type:Individual
Prefix:
First Name:ANDRINA
Middle Name:VERONICA
Last Name:MAMO
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 1:13001 E 17TH PL # 4529
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-2570
Mailing Address - Country:US
Mailing Address - Phone:248-974-2438
Mailing Address - Fax:
Practice Address - Street 1:13001 E 17TH PL # 4529
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2570
Practice Address - Country:US
Practice Address - Phone:248-974-2438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1038095578Medicaid