Provider Demographics
NPI:1760127773
Name:OUTLAW, NAFISA SADE
Entity Type:Individual
Prefix:
First Name:NAFISA
Middle Name:SADE
Last Name:OUTLAW
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 1:5804 N MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-1315
Mailing Address - Country:US
Mailing Address - Phone:268-368-3955
Mailing Address - Fax:
Practice Address - Street 1:5804 N MARSHALL ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19120-1315
Practice Address - Country:US
Practice Address - Phone:268-368-3955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA739258171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171000000XOther Service ProvidersMilitary Health Care ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0813Medicaid
PA822689610Medicaid