Provider Demographics
NPI:1144709247
Name:FOMENKY, SHEILA
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:FOMENKY
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 1:3600 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7311
Mailing Address - Country:US
Mailing Address - Phone:417-322-6622
Mailing Address - Fax:417-350-1935
Practice Address - Street 1:3600 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7311
Practice Address - Country:US
Practice Address - Phone:417-322-6622
Practice Address - Fax:417-350-1935
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX869928163W00000X
MO2021032055363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner