Provider Demographics
NPI:1861804221
Name:KOUMANIMBEN, FIDELE (PN151506-M-IV)
Entity type:Individual
Prefix:
First Name:FIDELE
Middle Name:
Last Name:KOUMANIMBEN
Suffix:
Gender:F
Credentials:PN151506-M-IV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5254 CAMELOT DR APT D
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4022
Mailing Address - Country:US
Mailing Address - Phone:513-497-8095
Mailing Address - Fax:
Practice Address - Street 1:5254 CAMELOT DR APT D
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-4022
Practice Address - Country:US
Practice Address - Phone:513-497-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.151506-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse