Provider Demographics
NPI:1427616739
Name:FOFANA, ALPHA FODAY
Entity type:Individual
Prefix:
First Name:ALPHA
Middle Name:FODAY
Last Name:FOFANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 WHEATFIELD CT
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77469-5360
Mailing Address - Country:US
Mailing Address - Phone:832-341-7536
Mailing Address - Fax:
Practice Address - Street 1:1110 WHEATFIELD CT
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77469-5360
Practice Address - Country:US
Practice Address - Phone:832-341-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TM1800X
TX217297164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities