Provider Demographics
NPI:1609617703
Name:TALA, PATRICIA MAFORNGWAHFOR
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:MAFORNGWAHFOR
Last Name:TALA
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 1:10203 BIRDIE LN
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-6068
Mailing Address - Country:US
Mailing Address - Phone:240-486-2745
Mailing Address - Fax:
Practice Address - Street 1:9135 PISCATAWAY RD STE 410
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-2555
Practice Address - Country:US
Practice Address - Phone:240-643-1063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR224410363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health