Provider Demographics
NPI:1558951285
Name:FOMINYAM, ANCELLA W (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANCELLA
Middle Name:W
Last Name:FOMINYAM
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:ANCELLA
Other - Middle Name:W
Other - Last Name:FOMINYAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MONTHE-TABOD
Mailing Address - Street 1:7826 EASTERN AVE NW STE 206
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1333
Mailing Address - Country:US
Mailing Address - Phone:240-350-8854
Mailing Address - Fax:
Practice Address - Street 1:7826 EASTERN AVE NW STE 206
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1333
Practice Address - Country:US
Practice Address - Phone:240-350-8854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1035937163W00000X
DCNP1035937363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse