Healthcare Provider Details

I. General information

NPI: 1306056965
Provider Name (Legal Business Name): KIRA FONBAH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 CLEARBROOK RD STE 103
HOOVER AL
35226-1573
US

IV. Provider business mailing address

815 BYRON WAY
HOOVER AL
35226-2429
US

V. Phone/Fax

Practice location:
  • Phone: 205-746-8542
  • Fax:
Mailing address:
  • Phone: 205-746-8542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number28627
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: