Provider Demographics
NPI:1750050522
Name:NDOMO, SOSTHENE MBALLA (NP)
Entity Type:Individual
Prefix:MR
First Name:SOSTHENE
Middle Name:MBALLA
Last Name:NDOMO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:SOSTHENE
Other - Middle Name:
Other - Last Name:NDOMO MBALLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6463 ROCKSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22315-3428
Mailing Address - Country:US
Mailing Address - Phone:571-208-6962
Mailing Address - Fax:
Practice Address - Street 1:6463 ROCKSHIRE CT
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-3428
Practice Address - Country:US
Practice Address - Phone:571-208-6962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182625164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024182625OtherVIRGINIA DEPARTMENT OF HEALTH PROFESSIONS