Provider Demographics
NPI:1639890908
Name:FOMBAN, STANLEY DINGBOBGA (APRN)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:DINGBOBGA
Last Name:FOMBAN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2349 INDIAN KEY DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY
Mailing Address - State:FL
Mailing Address - Zip Code:34691-7812
Mailing Address - Country:US
Mailing Address - Phone:172-745-2889
Mailing Address - Fax:
Practice Address - Street 1:2349 INDIAN KEY DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34691-7812
Practice Address - Country:US
Practice Address - Phone:727-452-8897
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11021138363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily