Provider Demographics
NPI:1639437254
Name:DIALLO-BANGURAH, KADIATOU (PMHNP)
Entity Type:Individual
Prefix:
First Name:KADIATOU
Middle Name:
Last Name:DIALLO-BANGURAH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 SANTA ROSALIA DR STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3614
Mailing Address - Country:US
Mailing Address - Phone:301-273-5066
Mailing Address - Fax:323-209-3439
Practice Address - Street 1:3756 SANTA ROSALIA DR STE 400
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90008-3614
Practice Address - Country:US
Practice Address - Phone:301-273-5066
Practice Address - Fax:323-209-3439
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2024-02-13
Deactivation Date:2023-11-30
Deactivation Code:
Reactivation Date:2024-01-29
Provider Licenses
StateLicense IDTaxonomies
MDR155931163W00000X
CA95028179363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse