Provider Demographics
NPI:1154735330
Name:FOMBA, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:FOMBA
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 1:1420 K ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20005-2500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 K ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-2500
Practice Address - Country:US
Practice Address - Phone:202-293-2931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN 1024462163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse