Provider Demographics
NPI:1528676046
Name:FONGOD, JOSEPH NDANGOH (FNP-C)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:NDANGOH
Last Name:FONGOD
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1289 HEARTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3070
Mailing Address - Country:US
Mailing Address - Phone:404-432-9400
Mailing Address - Fax:
Practice Address - Street 1:1289 HEARTWOOD AVE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3070
Practice Address - Country:US
Practice Address - Phone:404-432-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN199160363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily