Provider Demographics
NPI:1811881170
Name:FOMBON, LAETITIA
Entity type:Individual
Prefix:
First Name:LAETITIA
Middle Name:
Last Name:FOMBON
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 1:1512 E GRIFFIN PKWY STE 5
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:TX
Mailing Address - Zip Code:78572-2422
Mailing Address - Country:US
Mailing Address - Phone:956-600-8991
Mailing Address - Fax:
Practice Address - Street 1:1512 E GRIFFIN PKWY STE 5
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-2422
Practice Address - Country:US
Practice Address - Phone:956-600-8991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-03
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312120261QA0600X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care