Provider Demographics
NPI:1043627920
Name:FOFANA, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:FOFANA
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 1:6500 VEGAS DR
Mailing Address - Street 2:APT # 2120
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-7707
Mailing Address - Country:US
Mailing Address - Phone:760-646-0535
Mailing Address - Fax:
Practice Address - Street 1:6396 MCLEOD DR
Practice Address - Street 2:9
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4428
Practice Address - Country:US
Practice Address - Phone:702-912-0600
Practice Address - Fax:702-912-0601
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-12
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker