Provider Demographics
NPI:1982121976
Name:DIATTA, MYRIAM (NP)
Entity type:Individual
Prefix:
First Name:MYRIAM
Middle Name:
Last Name:DIATTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 LONDONLEAF LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2902
Mailing Address - Country:US
Mailing Address - Phone:202-390-6990
Mailing Address - Fax:
Practice Address - Street 1:14502 GREENVIEW DR # 500L21
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3287
Practice Address - Country:US
Practice Address - Phone:301-728-3574
Practice Address - Fax:940-514-9077
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-29
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187091363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily