Provider Demographics
NPI:1851968614
Name:FOMBO, CHANELLE INJEH KUNSEH (NP)
Entity type:Individual
Prefix:
First Name:CHANELLE
Middle Name:INJEH KUNSEH
Last Name:FOMBO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 AIR PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-3000
Mailing Address - Country:US
Mailing Address - Phone:903-408-5834
Mailing Address - Fax:903-408-5693
Practice Address - Street 1:4215 JOE RAMSEY BLVD E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-7852
Practice Address - Country:US
Practice Address - Phone:903-408-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024188872363L00000X
TX1019684363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner