Healthcare Provider Details

I. General information

NPI: 1194434738
Provider Name (Legal Business Name): BELINDA FOMBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 05/04/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORT DEFIANCE AZ
86504-0649
US

IV. Provider business mailing address

PO BOX 649
FORT DEFIANCE AZ
86504-0649
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number219337
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number219337
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: