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General NPI Number Information
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NPI Number | 1215638465
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Entity Type | Individual
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Provider Name | MASERAY FOFANAH FNP
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Gender | Female
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Dates
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Enumeration Date | 03/14/2023
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Last Update Date | 03/14/2023
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Provider Practice Location Address
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Address Line | 1717 W NORTHERN AVE STE 211
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City | PHOENIX
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State | AZ
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Zip | 85021-5469
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Country | US
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Telephone | 480-249-2655
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Fax |
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Provider Business Mailing Address
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Address Line | 257 N STATE RD APT 25A
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City | SPRINGFIELD
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State | PA
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Zip | 19064-1826
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Country | US
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Telephone | 161-076-6149
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1068830
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License Number State | TX
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