Provider Demographics
NPI:1912543893
Name:JALLOH, ISATA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:ISATA
Middle Name:
Last Name:JALLOH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18204 DANBY PL
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-1675
Mailing Address - Country:US
Mailing Address - Phone:240-291-5507
Mailing Address - Fax:
Practice Address - Street 1:235 MILL ST, HAGERSTOWN MD, 21740
Practice Address - Street 2:SAME AS ABOVE
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6668
Practice Address - Country:US
Practice Address - Phone:732-406-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-26
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR221446363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDNPIMedicaid