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General NPI Number Information
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NPI Number | 1265028781
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Entity Type | Individual
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Provider Name | KENNETH ELAD FONGUCK
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Gender | Male
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Dates
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Enumeration Date | 12/18/2020
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Last Update Date | 03/19/2026
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Provider Practice Location Address
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Address Line | 1 CVS DR
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City | WOONSOCKET
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State | RI
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Zip | 02895-6146
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Country | US
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Telephone | 402-419-6291
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Fax |
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Provider Business Mailing Address
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Address Line | 3768 SOUTHFIELD CT
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City | LOGANVILLE
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State | GA
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Zip | 30052-4863
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Country | US
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Telephone | 404-643-9031
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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 | APRN-NP296175
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License Number State | GA
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