Provider Demographics
NPI:1013442102
Name:FOMUJANG, MAFON (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MAFON
Middle Name:
Last Name:FOMUJANG
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32638 HARVEST VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BROOKSHIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77423-2908
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2911 MEDICAL ARTS ST STE 10
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-3302
Practice Address - Country:US
Practice Address - Phone:866-473-0663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH023666364SP0808X, 364SP0808X
OHAPRN.CNP.023666363LP0808X
TX1048371363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health