Provider Demographics
NPI:1902475148
Name:IDRISSOU, MARIAMA
Entity Type:Individual
Prefix:
First Name:MARIAMA
Middle Name:
Last Name:IDRISSOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5602 CYPRESS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-3505
Mailing Address - Country:US
Mailing Address - Phone:929-248-9029
Mailing Address - Fax:
Practice Address - Street 1:5602 CYPRESS CREEK DR
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-3505
Practice Address - Country:US
Practice Address - Phone:929-248-9029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA0019474376K00000X
MDA00194374376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide