Provider Demographics
NPI:1104532944
Name:AYONGABA, FONABEI
Entity type:Individual
Prefix:
First Name:FONABEI
Middle Name:
Last Name:AYONGABA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W GOWE ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-5892
Mailing Address - Country:US
Mailing Address - Phone:253-833-7444
Mailing Address - Fax:
Practice Address - Street 1:605 WOODLAND SQUARE LOOP SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1045
Practice Address - Country:US
Practice Address - Phone:844-949-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61094794163W00000X
WAAP61475276363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse