Provider Demographics
NPI:1942889738
Name:FOFANAH, MANU A
Entity Type:Individual
Prefix:
First Name:MANU
Middle Name:A
Last Name:FOFANAH
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 1:9943 GOOD LUCK RD APT 204
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-3264
Mailing Address - Country:US
Mailing Address - Phone:240-758-7040
Mailing Address - Fax:410-946-2010
Practice Address - Street 1:9943 GOOD LUCK RD APT 204
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3264
Practice Address - Country:US
Practice Address - Phone:240-758-7040
Practice Address - Fax:410-946-2010
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00140316376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide