Provider Demographics
NPI:1215685565
Name:FOMOND, TAKALA B (LPN)
Entity type:Individual
Prefix:MISS
First Name:TAKALA
Middle Name:B
Last Name:FOMOND
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 CENTRAL ST # 2A
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1212
Mailing Address - Country:US
Mailing Address - Phone:224-420-6894
Mailing Address - Fax:
Practice Address - Street 1:2916 CENTRAL ST # 2
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1212
Practice Address - Country:US
Practice Address - Phone:224-420-6894
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-15
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.117753164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse