Healthcare Provider Details

I. General information

NPI: 1124481882
Provider Name (Legal Business Name): OUMOU FORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 03/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3351 S 51ST ST
MILWAUKEE WI
53219-4516
US

IV. Provider business mailing address

3351 S 51ST ST
MILWAUKEE WI
53219-4516
US

V. Phone/Fax

Practice location:
  • Phone: 414-460-6868
  • Fax:
Mailing address:
  • Phone: 414-460-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number347C00000
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: