Provider Demographics
NPI:1093416240
Name:FONKEM, SOLANGE AJUA
Entity Type:Individual
Prefix:MS
First Name:SOLANGE
Middle Name:AJUA
Last Name:FONKEM
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 1:4321 SODA CREEK RD APT 2
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1120
Mailing Address - Country:US
Mailing Address - Phone:571-201-9770
Mailing Address - Fax:
Practice Address - Street 1:4321 SODA CREEK RD APT 2
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-1120
Practice Address - Country:US
Practice Address - Phone:571-201-9770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001243511163W00000X
WI259219-30163W00000X
IL209028537367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse