Provider Demographics
NPI:1366100786
Name:MEKOLLE, MAH
Entity type:Individual
Prefix:
First Name:MAH
Middle Name:
Last Name:MEKOLLE
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 1:6 CABINET MAKER CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-8840
Mailing Address - Country:US
Mailing Address - Phone:310-591-9307
Mailing Address - Fax:
Practice Address - Street 1:3300 N TRIUMPH BLVD STE 500
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-6475
Practice Address - Country:US
Practice Address - Phone:801-821-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12569009-4405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health