Provider Demographics
NPI:1548979107
Name:FOFANAH, ABDUL MALIK (NP)
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:MALIK
Last Name:FOFANAH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 N CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-5760
Mailing Address - Country:US
Mailing Address - Phone:240-441-7536
Mailing Address - Fax:
Practice Address - Street 1:2115 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218-5760
Practice Address - Country:US
Practice Address - Phone:240-441-7536
Practice Address - Fax:443-449-5651
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR215797363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health