Provider Demographics
NPI:1104352665
Name:FOMUNUNG-NGAM, ERNESTINE PENVAGA (ARNP)
Entity type:Individual
Prefix:
First Name:ERNESTINE
Middle Name:PENVAGA
Last Name:FOMUNUNG-NGAM
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:ERNESTINE
Other - Middle Name:PENVAGA
Other - Last Name:FOMUNUNG-NGAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6748 GALL BLVD
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-2511
Mailing Address - Country:US
Mailing Address - Phone:813-779-1209
Mailing Address - Fax:813-779-1216
Practice Address - Street 1:2010 WELLNESS WAY STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4142
Practice Address - Country:US
Practice Address - Phone:702-877-0814
Practice Address - Fax:702-877-3238
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9310637363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner