Healthcare Provider Details

I. General information

NPI: 1609708817
Provider Name (Legal Business Name): FENOT SAMUEL AWALOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ORANGE ST APT 604
NEW HAVEN CT
06510-3192
US

IV. Provider business mailing address

108 ORANGE ST APT 604
NEW HAVEN CT
06510-3192
US

V. Phone/Fax

Practice location:
  • Phone: 678-467-8062
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP.AP.70139029-NP
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: