Provider Demographics
NPI:1851968614
Name:FOMBO, CHANELLE (NP)
Entity Type:Individual
Prefix:
First Name:CHANELLE
Middle Name:
Last Name:FOMBO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2929 WYCLIFF AVE APT 2319
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-6652
Mailing Address - Country:US
Mailing Address - Phone:513-479-6240
Mailing Address - Fax:
Practice Address - Street 1:400 SENTARA CIR STE 201A
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5716
Practice Address - Country:US
Practice Address - Phone:757-984-3975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1019684363LA2100X
VA0024188872363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care