Provider Demographics
NPI:1871142307
Name:ELBA, ADOMALE (DNP)
Entity type:Individual
Prefix:DR
First Name:ADOMALE
Middle Name:
Last Name:ELBA
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6024 SMOOTH STONE PL
Mailing Address - Street 2:
Mailing Address - City:HAYMARKET
Mailing Address - State:VA
Mailing Address - Zip Code:20169-3310
Mailing Address - Country:US
Mailing Address - Phone:443-722-9277
Mailing Address - Fax:
Practice Address - Street 1:36 RICKETTS DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-3676
Practice Address - Country:US
Practice Address - Phone:540-535-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177746363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000000OtherNONE