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General NPI Number Information
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NPI Number | 1225802168
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Entity Type | Individual
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Provider Name | MAXINE FOMUNUNG
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Gender | Female
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Dates
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Enumeration Date | 11/10/2023
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Last Update Date | 03/18/2025
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Provider Practice Location Address
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Address Line | 409 OLD BORING LN
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City | WOODSTOCK
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State | GA
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Zip | 30189-2495
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Country | US
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Telephone | 470-461-3426
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Fax | 770-928-7558
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Provider Business Mailing Address
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Address Line | 3206 THIMBLEBERRY TRL
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City | DACULA
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State | GA
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Zip | 30019-7299
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Country | US
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Telephone | 470-461-3426
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | RN291792
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License Number State | GA
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