Provider Demographics
NPI:1427884667
Name:FONCHAM, IRENE NINA
Entity type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:NINA
Last Name:FONCHAM
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 1:3531 SEAGRASS LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-2488
Mailing Address - Country:US
Mailing Address - Phone:240-603-3438
Mailing Address - Fax:
Practice Address - Street 1:14901 BROSCHART RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3318
Practice Address - Country:US
Practice Address - Phone:301-251-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR184453363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health