Provider Demographics
NPI:1588349609
Name:FOMUKOM, NELSON NJI FANSO
Entity type:Individual
Prefix:
First Name:NELSON
Middle Name:NJI FANSO
Last Name:FOMUKOM
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 1:7847 RIVERDALE RD APT 303
Mailing Address - Street 2:
Mailing Address - City:NEW CARROLLTON
Mailing Address - State:MD
Mailing Address - Zip Code:20784-4008
Mailing Address - Country:US
Mailing Address - Phone:202-867-4406
Mailing Address - Fax:
Practice Address - Street 1:7847 RIVERDALE RD APT 303
Practice Address - Street 2:
Practice Address - City:NEW CARROLLTON
Practice Address - State:MD
Practice Address - Zip Code:20784-4008
Practice Address - Country:US
Practice Address - Phone:202-867-4406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health