Provider Demographics
NPI:1447779590
Name:FOMBANG, MELANIE D
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:D
Last Name:FOMBANG
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 1:108 S. WILLIAM BARNETT AVE.
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TX
Mailing Address - Zip Code:77327
Mailing Address - Country:US
Mailing Address - Phone:281-592-9775
Mailing Address - Fax:281-592-1570
Practice Address - Street 1:8484 WILL CLAYTON PKWY
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338
Practice Address - Country:US
Practice Address - Phone:832-995-5200
Practice Address - Fax:832-995-5219
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134868363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1639165129Medicaid