Provider Demographics
NPI:1225802168
Name:FOMUNUNG, MAXINE
Entity type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:FOMUNUNG
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 1:3206 THIMBLEBERRY TRL
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7299
Mailing Address - Country:US
Mailing Address - Phone:470-461-3426
Mailing Address - Fax:
Practice Address - Street 1:409 OLD BORING LN
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-2495
Practice Address - Country:US
Practice Address - Phone:470-461-3426
Practice Address - Fax:770-928-7558
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN291792363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health