Provider Demographics
NPI:1790477396
Name:DOMFANG FOTSO, FIONA IMELDA
Entity Type:Individual
Prefix:
First Name:FIONA
Middle Name:IMELDA
Last Name:DOMFANG FOTSO
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 1:6733 NEW HAMPSHIRE AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-2842
Mailing Address - Country:US
Mailing Address - Phone:315-572-9327
Mailing Address - Fax:
Practice Address - Street 1:6733 NEW HAMPSHIRE AVE APT 304
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-2842
Practice Address - Country:US
Practice Address - Phone:315-572-9327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC0000813357374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide