Provider Demographics
NPI:1477169936
Name:POPOOLA, MUTIAT O (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MUTIAT
Middle Name:O
Last Name:POPOOLA
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:337 BRIGHTSEAT RD STE 201
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-4736
Mailing Address - Country:US
Mailing Address - Phone:240-988-3779
Mailing Address - Fax:
Practice Address - Street 1:15518 KENNETT SQUARE WAY
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-6239
Practice Address - Country:US
Practice Address - Phone:240-988-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205702363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherOPTIONAL