Provider Demographics
NPI:1871169102
Name:FOFANAH, AMINATA S
Entity type:Individual
Prefix:
First Name:AMINATA
Middle Name:S
Last Name:FOFANAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5237 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-2857
Mailing Address - Country:US
Mailing Address - Phone:240-310-6263
Mailing Address - Fax:410-946-2010
Practice Address - Street 1:5237 KENILWORTH AVE
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20781-2857
Practice Address - Country:US
Practice Address - Phone:240-310-6263
Practice Address - Fax:410-946-2010
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00061822376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide