Basic Information
| Provider Information | |||||||||
| NPI: | 1134634538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOUAFO | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | VANESSA | ||||||||
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| Credential: | NP-FAMILY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 N CHARLES ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212015505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4108372050 | ||||||||
| FaxNumber: | 8666290091 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 ANNAPOLIS RD | ||||||||
| Address2: | |||||||||
| City: | ODENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211131602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4433513917 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2017 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F11170058 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | R179754 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.