Provider Demographics
NPI:1447511167
Name:FRU, FRIDA MAMBO
Entity type:Individual
Prefix:MRS
First Name:FRIDA
Middle Name:MAMBO
Last Name:FRU
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 1:17505 MADRILLON WAY
Mailing Address - Street 2:
Mailing Address - City:ACCOKEEK
Mailing Address - State:MD
Mailing Address - Zip Code:20607-3457
Mailing Address - Country:US
Mailing Address - Phone:301-273-5103
Mailing Address - Fax:
Practice Address - Street 1:6 DUPONT CIR NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-1108
Practice Address - Country:US
Practice Address - Phone:301-273-5103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR202495363LF0000X
DCRN1032808363LF0000X
MDR202945363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily