Provider Demographics
NPI:1962027755
Name:MOUKDAGOU, SALY DAMIGOU (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:SALY
Middle Name:DAMIGOU
Last Name:MOUKDAGOU
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10821 CLOVER CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-7246
Mailing Address - Country:US
Mailing Address - Phone:571-267-0628
Mailing Address - Fax:
Practice Address - Street 1:12255 FAIR LAKES PKWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-3952
Practice Address - Country:US
Practice Address - Phone:703-934-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001279380163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent