Provider Demographics
NPI:1194147264
Name:FONGE, YVONNE
Entity type:Individual
Prefix:
First Name:YVONNE
Middle Name:
Last Name:FONGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 AUTUMN GOLD CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-5419
Mailing Address - Country:US
Mailing Address - Phone:404-512-0791
Mailing Address - Fax:
Practice Address - Street 1:6420 AUTUMN GOLD CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-5419
Practice Address - Country:US
Practice Address - Phone:404-512-0791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1031761163W00000X
MDR207998163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse