Provider Demographics
NPI:1730848029
Name:FOFANA, SHEKU (FNP)
Entity type:Individual
Prefix:
First Name:SHEKU
Middle Name:
Last Name:FOFANA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-248-7000
Mailing Address - Fax:310-248-7033
Practice Address - Street 1:10780 SANTA MONICA BLVD STE 105
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-7613
Practice Address - Country:US
Practice Address - Phone:424-521-1066
Practice Address - Fax:424-326-8553
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019700363LF0000X, 363LP0808X
CA95098561163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health