Provider Demographics
NPI:1336763176
Name:DIALLO, FATOUMATA (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:FATOUMATA
Middle Name:
Last Name:DIALLO
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-865-3848
Mailing Address - Fax:704-854-3086
Practice Address - Street 1:1337 E GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5127
Practice Address - Country:US
Practice Address - Phone:704-865-3848
Practice Address - Fax:919-933-6881
Is Sole Proprietor?:No
Enumeration Date:2020-06-07
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC217208363L00000X
NC5013368363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner