Provider Demographics
NPI:1548518970
Name:FOMINYAM, NICHOLAS MBAH (HHA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:MBAH
Last Name:FOMINYAM
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13902 CASTLE BOULEVARD
Mailing Address - Street 2:APT 202
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904
Mailing Address - Country:US
Mailing Address - Phone:703-638-5033
Mailing Address - Fax:
Practice Address - Street 1:7826 EASTERN AVENUE NW
Practice Address - Street 2:LI18
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012
Practice Address - Country:US
Practice Address - Phone:202-722-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide