Provider Demographics
NPI:1245828383
Name:FOMBU, ANNE MARIE
Entity type:Individual
Prefix:
First Name:ANNE MARIE
Middle Name:
Last Name:FOMBU
Suffix:
Gender:
Credentials:
Other - Prefix:DR
Other - First Name:MARY ANNE
Other - Middle Name:
Other - Last Name:FOMBU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:15015 MAIN ST SUITE 109
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007
Mailing Address - Country:US
Mailing Address - Phone:206-575-0300
Mailing Address - Fax:
Practice Address - Street 1:15015 MAIN ST
Practice Address - Street 2:SUITE #109
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007
Practice Address - Country:US
Practice Address - Phone:509-824-6978
Practice Address - Fax:509-824-6961
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60860845163W00000X
WAAP61138151363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty