Provider Demographics
NPI:1437435419
Name:FOMENKO, SANDRA DAWN (MSN, AGPCNP-BC, CPNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DAWN
Last Name:FOMENKO
Suffix:
Gender:F
Credentials:MSN, AGPCNP-BC, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 WHITNEY AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06517-1209
Mailing Address - Country:US
Mailing Address - Phone:203-848-1803
Mailing Address - Fax:
Practice Address - Street 1:1952 WHITNEY AVE STE 3
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06517-1209
Practice Address - Country:US
Practice Address - Phone:203-848-1803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-22
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004756363LP0200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid