Provider Demographics
NPI:1619466323
Name:MUTOMBO, HENRIETTE
Entity Type:Individual
Prefix:
First Name:HENRIETTE
Middle Name:
Last Name:MUTOMBO
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 1:8902 STABLE FOREST PL
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:VA
Mailing Address - Zip Code:20136-5762
Mailing Address - Country:US
Mailing Address - Phone:571-364-4530
Mailing Address - Fax:
Practice Address - Street 1:8902 STABLE FOREST PL
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-5762
Practice Address - Country:US
Practice Address - Phone:571-364-4530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1401071283374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide