Provider Demographics
NPI:1518734748
Name:MNONGERWA, FATUMA Y
Entity Type:Individual
Prefix:
First Name:FATUMA
Middle Name:Y
Last Name:MNONGERWA
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 1:15564 FUCHSIA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-5100
Mailing Address - Country:US
Mailing Address - Phone:208-570-4798
Mailing Address - Fax:
Practice Address - Street 1:1111 S ORCHARD ST STE 245
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1964
Practice Address - Country:US
Practice Address - Phone:208-570-4798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-44431101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health