Healthcare Provider Details

I. General information

NPI: 1225679368
Provider Name (Legal Business Name): BERNICE FOMUNUNG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 SW 11TH ST
CHEHALIS WA
98532-4700
US

IV. Provider business mailing address

3134 IZABELLA CT
FRISCO TX
75033-8068
US

V. Phone/Fax

Practice location:
  • Phone: 564-999-3410
  • Fax: 360-740-3450
Mailing address:
  • Phone: 469-427-1482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP142982
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: