Individual
MR. SOSTHENE MBALLA NDOMO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
6463 ROCKSHIRE CT, ALEXANDRIA, VA 22315-3428
(571) 208-6962
Mailing address
206 BLOSSOM LN, STAFFORD, VA 22554-4869
(571) 208-6962
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
0024182625
VA
363L00000X
Nurse Practitioner
0024182625
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0024182625
VIRGINIA DEPARTMENT OF HEALTH PROFESSIONS
VA
Enumeration date
09/07/2021
Last updated
02/23/2026
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