Provider Demographics
NPI:1659649655
Name:KAGBO, MAHAWA MBALU (FNP)
Entity Type:Individual
Prefix:MS
First Name:MAHAWA
Middle Name:MBALU
Last Name:KAGBO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5864 WOOD FLOWER CT
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2713
Mailing Address - Country:US
Mailing Address - Phone:571-218-6565
Mailing Address - Fax:703-504-7662
Practice Address - Street 1:5864 WOOD FLOWER CT
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-2713
Practice Address - Country:US
Practice Address - Phone:571-218-6565
Practice Address - Fax:703-504-7662
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001169930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily