=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447955331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOPRINYE ELIM DAPPA-FOMBO MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2023
-----------------------------------------------------
Last Update Date | 03/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2649 SOUTH RD STE 104
-----------------------------------------------------
City | POUGHKEEPSIE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12601-6843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-667-9538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1825 EASTERN PKWY APT 2F
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11233-6905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-667-9538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------