Provider Demographics
NPI:1508996489
Name:FOMBU, COMFORT
Entity Type:Individual
Prefix:
First Name:COMFORT
Middle Name:
Last Name:FOMBU
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 1:2083 DORCHESTER AVE
Mailing Address - Street 2:APT. #3
Mailing Address - City:DORCHESTER CENTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-4795
Mailing Address - Country:US
Mailing Address - Phone:617-298-6949
Mailing Address - Fax:617-298-6949
Practice Address - Street 1:2083 DORCHESTER AVENUE
Practice Address - Street 2:APT. #3
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-4795
Practice Address - Country:US
Practice Address - Phone:617-298-6949
Practice Address - Fax:617-298-6949
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA262119163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health