Provider Demographics
NPI:1285056150
Name:FOFANA, FANTA
Entity type:Individual
Prefix:MS
First Name:FANTA
Middle Name:
Last Name:FOFANA
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 1:9729 GOOD LUCK RD APT 3
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3314
Mailing Address - Country:US
Mailing Address - Phone:240-354-1538
Mailing Address - Fax:
Practice Address - Street 1:9729 GOOD LUCK RD APT 3
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3314
Practice Address - Country:US
Practice Address - Phone:240-354-1538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA10231374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide