Provider Demographics
NPI:1578990222
Name:FOMINKA, BENARD NTEHMBO
Entity Type:Individual
Prefix:
First Name:BENARD
Middle Name:NTEHMBO
Last Name:FOMINKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9873 GOOD LUCK RD APT 10
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3230
Mailing Address - Country:US
Mailing Address - Phone:240-468-1129
Mailing Address - Fax:
Practice Address - Street 1:2512 24TH ST NE # E
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2126
Practice Address - Country:US
Practice Address - Phone:202-832-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1046452163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse