Provider Demographics
NPI:1700313707
Name:FOMUKONG, SALOME (HOME HEALTH AIDE)
Entity Type:Individual
Prefix:
First Name:SALOME
Middle Name:
Last Name:FOMUKONG
Suffix:
Gender:F
Credentials:HOME HEALTH AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6735 NEW HAMPSHIRE AVE #110
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1752 COLUMBIA RD #2
Practice Address - Street 2:TIERNO CARE HOME HEALTH AGENCY
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20009
Practice Address - Country:US
Practice Address - Phone:202-808-2362
Practice Address - Fax:202-808-2367
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide