Provider Demographics
NPI:1629764923
Name:MAMO, SEBELE T
Entity Type:Individual
Prefix:MRS
First Name:SEBELE
Middle Name:T
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 1:7657 AUDUBON MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-2280
Mailing Address - Country:US
Mailing Address - Phone:215-808-2559
Mailing Address - Fax:
Practice Address - Street 1:7657 AUDUBON MEADOW WAY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-2280
Practice Address - Country:US
Practice Address - Phone:215-808-2559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186756363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily