Provider Demographics
NPI:1093075731
Name:MISSIET FOGOUM, NADINE CAROLE (CRNP)
Entity Type:Individual
Prefix:
First Name:NADINE CAROLE
Middle Name:
Last Name:MISSIET FOGOUM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8625 SAVANNAH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20724-1956
Mailing Address - Country:US
Mailing Address - Phone:202-459-8904
Mailing Address - Fax:
Practice Address - Street 1:8625 SAVANNAH RIVER RD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-1956
Practice Address - Country:US
Practice Address - Phone:202-459-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-28
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR205038363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health