Provider Demographics
NPI:1013340348
Name:FONKEM, CACILIA
Entity Type:Individual
Prefix:
First Name:CACILIA
Middle Name:
Last Name:FONKEM
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 1:11700 OLD COLUMBIA PIKE APT 2105
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2559
Mailing Address - Country:US
Mailing Address - Phone:914-299-2812
Mailing Address - Fax:
Practice Address - Street 1:11700 OLD COLUMBIA PIKE APT 2105
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-2559
Practice Address - Country:US
Practice Address - Phone:914-299-2812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No374U00000XNursing Service Related ProvidersHome Health Aide