Healthcare Provider Details

I. General information

NPI: 1730848029
Provider Name (Legal Business Name): SHEKU FOFANA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10780 SANTA MONICA BLVD STE 105
LOS ANGELES CA
90025-7613
US

IV. Provider business mailing address

4140 W 190TH ST
TORRANCE CA
90504-5513
US

V. Phone/Fax

Practice location:
  • Phone: 424-521-1066
  • Fax: 424-326-8553
Mailing address:
  • Phone: 310-248-7000
  • Fax: 310-248-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95019700
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95098561
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95019700
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: