Healthcare Provider Details

I. General information

NPI: 1790517472
Provider Name (Legal Business Name): TIZI K FOBANJONG PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GROVE ST STE 203
WORCESTER MA
01605-2630
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE STE 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 508-250-8378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023191216
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN2342607
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: