Provider Demographics
NPI:1629504196
Name:FOMBY, TRAVONA
Entity Type:Individual
Prefix:
First Name:TRAVONA
Middle Name:
Last Name:FOMBY
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 1:38551 METRO VILLA DR UNIT 105Y
Mailing Address - Street 2:
Mailing Address - City:HARRISON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-5386
Mailing Address - Country:US
Mailing Address - Phone:248-291-7595
Mailing Address - Fax:
Practice Address - Street 1:38551 METRO VILLA DR UNIT 105Y
Practice Address - Street 2:
Practice Address - City:HARRISON TWP
Practice Address - State:MI
Practice Address - Zip Code:48045-5386
Practice Address - Country:US
Practice Address - Phone:248-291-7595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2300141167060408376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide