Provider Demographics
NPI:1154137040
Name:DJAMA, MAIMUNA
Entity type:Individual
Prefix:
First Name:MAIMUNA
Middle Name:
Last Name:DJAMA
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 1:457 W NOPAL AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-7415
Mailing Address - Country:US
Mailing Address - Phone:952-412-6273
Mailing Address - Fax:
Practice Address - Street 1:457 W NOPAL AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-7415
Practice Address - Country:US
Practice Address - Phone:952-412-6273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH9981324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility