Provider Demographics
NPI:1053955104
Name:KOROMA, FATU (NP)
Entity type:Individual
Prefix:
First Name:FATU
Middle Name:
Last Name:KOROMA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 CALUMET CT
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1060
Mailing Address - Country:US
Mailing Address - Phone:240-437-2705
Mailing Address - Fax:
Practice Address - Street 1:6490 LANDOVER RD
Practice Address - Street 2:
Practice Address - City:CHEVERLY
Practice Address - State:MD
Practice Address - Zip Code:20785-1443
Practice Address - Country:US
Practice Address - Phone:240-437-2705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-01
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187334363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner