Provider Demographics
NPI:1912599317
Name:KOROMA, FANTA BOMPORO
Entity type:Individual
Prefix:
First Name:FANTA
Middle Name:BOMPORO
Last Name:KOROMA
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 1:9522 MUIRKIRK RD APT 301
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-2736
Mailing Address - Country:US
Mailing Address - Phone:240-485-7735
Mailing Address - Fax:
Practice Address - Street 1:9522 MUIRKIRK RD APT 301
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-2736
Practice Address - Country:US
Practice Address - Phone:240-485-7735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251S00000XAgenciesCommunity/Behavioral Health
No376K00000XNursing Service Related ProvidersNurse's Aide