Provider Demographics
NPI:1225679368
Name:FOMUNUNG, BERNICE
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:FOMUNUNG
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 1:3134 IZABELLA CT
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-8068
Mailing Address - Country:US
Mailing Address - Phone:469-427-1482
Mailing Address - Fax:
Practice Address - Street 1:8501 WADE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-6262
Practice Address - Country:US
Practice Address - Phone:972-668-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142982363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health