Provider Demographics
NPI:1891317889
Name:DIALLO, MARIAMA (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:MARIAMA
Middle Name:
Last Name:DIALLO
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 PARK HAVEN LN
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1719
Mailing Address - Country:US
Mailing Address - Phone:678-541-1187
Mailing Address - Fax:
Practice Address - Street 1:3424 FLAT SHOALS RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-6525
Practice Address - Country:US
Practice Address - Phone:404-968-8269
Practice Address - Fax:404-968-8274
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN216662363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty