Basic Information
| Provider Information | |||||||||
| NPI: | 1962879395 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MBAH | ||||||||
| FirstName: | OPHILIA | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | X | ||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TOH | ||||||||
| OtherFirstName: | OPHILIA | ||||||||
| OtherMiddleName: | N. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4703 OLD SOPER RD | ||||||||
| Address2: | SUITE R-1 | ||||||||
| City: | CAMP SPRINGS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 20746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2402490989 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6856 EASTERN AVE NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 20012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2025456980 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2015 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN1028515 | DC | N | Nursing Service Providers | Registered Nurse | 363LP0808X | R205445 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.