Provider Demographics
NPI:1740791706
Name:AMLALO, CELESTINA
Entity Type:Individual
Prefix:
First Name:CELESTINA
Middle Name:
Last Name:AMLALO
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 1:11458 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-4200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11458 KINGS HWY
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-4200
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2021097680363LP0808X
VA0024175523363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health