Provider Demographics
NPI:1235992694
Name:FOFANAH, AUGUSTINA EVO (RN)
Entity Type:Individual
Prefix:
First Name:AUGUSTINA
Middle Name:EVO
Last Name:FOFANAH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 THISTLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-3901
Mailing Address - Country:US
Mailing Address - Phone:202-304-0633
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:2012 THISTLEWOOD DR
Practice Address - Street 2:
Practice Address - City:FT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-3901
Practice Address - Country:US
Practice Address - Phone:202-304-0633
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1037262163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal NewbornGroup - Single Specialty