Provider Demographics
NPI:1730348442
Name:FOMBO, DANIEL CHICK (MSN APN)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:CHICK
Last Name:FOMBO
Suffix:
Gender:M
Credentials:MSN APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 SAND PIT RD
Mailing Address - Street 2:STE. 308
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4032
Mailing Address - Country:US
Mailing Address - Phone:203-743-7264
Mailing Address - Fax:
Practice Address - Street 1:67 SAND PIT RD
Practice Address - Street 2:STE. 308
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4032
Practice Address - Country:US
Practice Address - Phone:203-743-7264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6100363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily