Provider Demographics
NPI:1053678532
Name:FOMINYEN, KENNETH A
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:FOMINYEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 NEW HAMPSHIRE AVE
Mailing Address - Street 2:APT# 814
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7401 NEW HAMPSHIRE AVE
Practice Address - Street 2:APT# 814
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6945
Practice Address - Country:US
Practice Address - Phone:202-722-1725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide