Provider Demographics
NPI:1720358567
Name:MUSTAPHA, MARIAMA
Entity Type:Individual
Prefix:
First Name:MARIAMA
Middle Name:
Last Name:MUSTAPHA
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 1:1580 WORTHINGTON CLUB DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-4621
Mailing Address - Country:US
Mailing Address - Phone:732-213-5974
Mailing Address - Fax:
Practice Address - Street 1:1580 WORTHINGTON CLUB DR
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-4621
Practice Address - Country:US
Practice Address - Phone:732-213-5974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH128971164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse