Provider Demographics
NPI:1609135250
Name:FOMINYAM, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:FOMINYAM
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 1:1818 NEW YORK AVE NE
Mailing Address - Street 2:228
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-1848
Mailing Address - Country:US
Mailing Address - Phone:202-832-8340
Mailing Address - Fax:
Practice Address - Street 1:1818 NEW YORK AVE NE
Practice Address - Street 2:228
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20002-1848
Practice Address - Country:US
Practice Address - Phone:202-832-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN7110164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse