Provider Demographics
NPI:1184318602
Name:ISMAIL, NITANGA
Entity type:Individual
Prefix:
First Name:NITANGA
Middle Name:
Last Name:ISMAIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NITANGA
Other - Middle Name:
Other - Last Name:ISHMAEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5125 BRIDGESIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-2859
Mailing Address - Country:US
Mailing Address - Phone:804-382-2592
Mailing Address - Fax:
Practice Address - Street 1:4100 PRICE CLUB BLVD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3379
Practice Address - Country:US
Practice Address - Phone:804-674-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician