Provider Demographics
NPI:1649741158
Name:GORRE-NDIAYE, MAGHAL M
Entity Type:Individual
Prefix:
First Name:MAGHAL
Middle Name:M
Last Name:GORRE-NDIAYE
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 1:646 TIVOLI RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-4528
Mailing Address - Country:US
Mailing Address - Phone:301-693-2785
Mailing Address - Fax:
Practice Address - Street 1:196 THOMAS JOHNSON DR STE 135
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4518
Practice Address - Country:US
Practice Address - Phone:301-200-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCR183425363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily