Healthcare Provider Details

I. General information

NPI: 1538688684
Provider Name (Legal Business Name): DR. JULIUS FOMENGIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2017
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13994 BALTIMORE AVE
LAUREL MD
20707-5087
US

IV. Provider business mailing address

7411 RIGGS RD STE 210
HYATTSVILLE MD
20783-4246
US

V. Phone/Fax

Practice location:
  • Phone: 240-463-3357
  • Fax:
Mailing address:
  • Phone: 240-463-3357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR148632
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR148632
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: