Provider Demographics
NPI:1316401979
Name:FOMELACHFOSSUNG, CORNELIUS SR
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:FOMELACHFOSSUNG
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 9TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-7217
Mailing Address - Country:US
Mailing Address - Phone:202-247-1076
Mailing Address - Fax:
Practice Address - Street 1:4201 9TH ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-7217
Practice Address - Country:US
Practice Address - Phone:202-247-1076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA14256374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide