Provider Demographics
NPI:1811250905
Name:MBOME, ANGEL VIVIAN (CRNP, PMHNP)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:VIVIAN
Last Name:MBOME
Suffix:
Gender:F
Credentials:CRNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 WAYNE AVE STE G100
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-4493
Mailing Address - Country:US
Mailing Address - Phone:301-615-8752
Mailing Address - Fax:240-503-3254
Practice Address - Street 1:801 WAYNE AVE STE G100
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4493
Practice Address - Country:US
Practice Address - Phone:301-615-8752
Practice Address - Fax:240-503-3254
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR217061363LP0808X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty