Provider Demographics
NPI:1154943686
Name:AKA FOMENKY, GEORGINA
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:AKA FOMENKY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 N MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2603
Mailing Address - Country:US
Mailing Address - Phone:972-518-1325
Mailing Address - Fax:
Practice Address - Street 1:5500 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2603
Practice Address - Country:US
Practice Address - Phone:972-518-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1089343363LF0000X
TX800512163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse