Provider Demographics
NPI:1558673376
Name:AYUKESONG, MFOMBU (CSA)
Entity type:Individual
Prefix:MR
First Name:MFOMBU
Middle Name:
Last Name:AYUKESONG
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:POSEN
Mailing Address - State:IL
Mailing Address - Zip Code:60469-0044
Mailing Address - Country:US
Mailing Address - Phone:708-566-4328
Mailing Address - Fax:708-589-3372
Practice Address - Street 1:14828 ARTESIAN AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-1313
Practice Address - Country:US
Practice Address - Phone:708-566-4328
Practice Address - Fax:708-589-3372
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2380000263174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist