Provider Demographics
NPI:1760658942
Name:COLOMBO, MORGANA LUSTOSA
Entity Type:Individual
Prefix:
First Name:MORGANA
Middle Name:LUSTOSA
Last Name:COLOMBO
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 1:4660 KENMORE AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1300
Mailing Address - Country:US
Mailing Address - Phone:703-370-0073
Mailing Address - Fax:
Practice Address - Street 1:4660 KENMORE AVE STE 500
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1300
Practice Address - Country:US
Practice Address - Phone:703-370-0073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-07
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249297207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology