Provider Demographics
NPI:1962867267
Name:DIALLO FOFANA, MARIAM (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:DIALLO FOFANA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 GOLF RD # 1250
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4711 GOLF RD # 1250
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:847-235-6033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-31
Last Update Date:2015-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013531363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily