Provider Demographics
NPI:1699666115
Name:FOFANG, NINA
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:FOFANG
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 1:301 S GLENDORA AVE UNIT 2544
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-5938
Mailing Address - Country:US
Mailing Address - Phone:972-352-7743
Mailing Address - Fax:
Practice Address - Street 1:301 S GLENDORA AVE UNIT 2544
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-5938
Practice Address - Country:US
Practice Address - Phone:972-352-7743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-12
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95221764163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse