Provider Demographics
NPI:1730810649
Name:FOFANA, MASSANDJE BAKAYOKO (PMHNP)
Entity type:Individual
Prefix:
First Name:MASSANDJE
Middle Name:BAKAYOKO
Last Name:FOFANA
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2739 EGRET WAY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-1913
Mailing Address - Country:US
Mailing Address - Phone:240-291-3934
Mailing Address - Fax:
Practice Address - Street 1:6501 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-6819
Practice Address - Country:US
Practice Address - Phone:410-938-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR194310103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent