Provider Demographics
NPI:1467325985
Name:FAAL, MAMKUMBA (FNP)
Entity type:Individual
Prefix:
First Name:MAMKUMBA
Middle Name:
Last Name:FAAL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 FORGE POND LN
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-4267
Mailing Address - Country:US
Mailing Address - Phone:248-982-2445
Mailing Address - Fax:
Practice Address - Street 1:1585 FORGE POND LN
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-4267
Practice Address - Country:US
Practice Address - Phone:248-982-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-29
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1213294363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty