Provider Demographics
NPI:1710338546
Name:KOUAKEU, MENO MAZEMDA (NP)
Entity Type:Individual
Prefix:MS
First Name:MENO
Middle Name:MAZEMDA
Last Name:KOUAKEU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4007 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-1304
Mailing Address - Country:US
Mailing Address - Phone:757-292-9094
Mailing Address - Fax:
Practice Address - Street 1:1201 S HAYES ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-2700
Practice Address - Country:US
Practice Address - Phone:757-292-9094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0024173643363LF0000X
VA0024173643363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily