Provider Demographics
NPI:1417366063
Name:FOMA, JEANNE (NP-FAMILY)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:FOMA
Suffix:
Gender:F
Credentials:NP-FAMILY
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:
Other - Last Name:MAFOKOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:154 FORREST DR
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-5511
Mailing Address - Country:US
Mailing Address - Phone:301-455-0939
Mailing Address - Fax:
Practice Address - Street 1:154 FORREST DR
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-5511
Practice Address - Country:US
Practice Address - Phone:301-455-0939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194210363LF0000X
MO2017036737363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily