Healthcare Provider Details

I. General information

NPI: 1417893843
Provider Name (Legal Business Name): FATOMATA SANUWO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2026
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552 SOUTHERN BLVD
BRONX NY
10455-3715
US

IV. Provider business mailing address

1348 WEBSTER AVE APT 2F
BRONX NY
10456-1852
US

V. Phone/Fax

Practice location:
  • Phone: 718-858-8585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: