Provider Demographics
NPI:1790382810
Name:FOMIN, AMY MARIE
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:FOMIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:FOMIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:39205 COUNTRY CLUB DR STE C26
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-5718
Mailing Address - Country:US
Mailing Address - Phone:248-365-6109
Mailing Address - Fax:
Practice Address - Street 1:39205 COUNTRY CLUB DR STE C26
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-5718
Practice Address - Country:US
Practice Address - Phone:248-365-6109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704201285163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse