Provider Demographics
NPI:1033450952
Name:TELAZIE-SIMONS, JOAN FOMBOH (RN)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:FOMBOH
Last Name:TELAZIE-SIMONS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:
Other - Last Name:FOMBOH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:310 W LOSEY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT AIR FORCE BASE
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5250
Mailing Address - Country:US
Mailing Address - Phone:618-256-9355
Mailing Address - Fax:
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AIR FORCE BASE
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR226483163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse