Provider Demographics
NPI:1124414750
Name:FOMUNUNG, COLLINS FOKUM (FNP)
Entity Type:Individual
Prefix:
First Name:COLLINS
Middle Name:FOKUM
Last Name:FOMUNUNG
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 WHITE WATER FALLS DR APT 611
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-5257
Mailing Address - Country:US
Mailing Address - Phone:704-258-2936
Mailing Address - Fax:
Practice Address - Street 1:6608 E W T HARRIS BLVD STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-5128
Practice Address - Country:US
Practice Address - Phone:704-900-7761
Practice Address - Fax:704-900-8058
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF0215602363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily