Healthcare Provider Details

I. General information

NPI: 1205798642
Provider Name (Legal Business Name): MARY RUTH FOFANAH NA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 RIVERS EDGE DR
FREDERICKSBURG VA
22405-1298
US

IV. Provider business mailing address

509 RIVERS EDGE DR
FREDERICKSBURG VA
22405-1298
US

V. Phone/Fax

Practice location:
  • Phone: 571-501-5981
  • Fax: 571-501-5981
Mailing address:
  • Phone: 571-501-5981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number1401103712
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: