Provider Demographics
NPI:1912572652
Name:KALLON, MAMAWA LOVETTE (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:MAMAWA
Middle Name:LOVETTE
Last Name:KALLON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 ROCK SPRING RD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2607
Mailing Address - Country:US
Mailing Address - Phone:443-640-4524
Mailing Address - Fax:
Practice Address - Street 1:1307 MERRITT BLVD
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2109
Practice Address - Country:US
Practice Address - Phone:410-288-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR177881363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily