Provider Demographics
NPI:1811336803
Name:FOMUKONG, VIVIAN ANGYIAHEN
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:ANGYIAHEN
Last Name:FOMUKONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9276 ADELPHI RD APT 204
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20783-2029
Mailing Address - Country:US
Mailing Address - Phone:202-378-6632
Mailing Address - Fax:
Practice Address - Street 1:9276 ADELPHI RD APT 204
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-2029
Practice Address - Country:US
Practice Address - Phone:202-378-6632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-23
Last Update Date:2013-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA8384364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome Health