Provider Demographics
NPI:1619597663
Name:FOFUNG, THERESIA DIMIA (RN)
Entity Type:Individual
Prefix:
First Name:THERESIA
Middle Name:DIMIA
Last Name:FOFUNG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14804 ASHFORD PL
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3770
Mailing Address - Country:US
Mailing Address - Phone:301-270-7089
Mailing Address - Fax:
Practice Address - Street 1:1508 E CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-1507
Practice Address - Country:US
Practice Address - Phone:202-371-9393
Practice Address - Fax:202-697-5069
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-20
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1056507163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse