Provider Demographics
NPI:1023684867
Name:KOROMA, KHADIJATU (NURSE PRACTIONER)
Entity type:Individual
Prefix:
First Name:KHADIJATU
Middle Name:
Last Name:KOROMA
Suffix:
Gender:F
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7012 E CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-2106
Mailing Address - Country:US
Mailing Address - Phone:301-254-1169
Mailing Address - Fax:
Practice Address - Street 1:14446 LAYHILL RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20906-1911
Practice Address - Country:US
Practice Address - Phone:301-598-0725
Practice Address - Fax:301-598-0729
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-02
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR181191163W00000X
MDF05210435363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse