Provider Demographics
NPI:1205429941
Name:NDAPTSO, MIRIANDA MAZONGEH
Entity type:Individual
Prefix:
First Name:MIRIANDA
Middle Name:MAZONGEH
Last Name:NDAPTSO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 EDGEFIELD DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-7665
Mailing Address - Country:US
Mailing Address - Phone:678-497-5145
Mailing Address - Fax:
Practice Address - Street 1:3008 EDGEFIELD DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-7665
Practice Address - Country:US
Practice Address - Phone:678-497-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-13
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NPO00690363L00000X, 363LP0808X
MO2016043488363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health