MEDICARE: COLLINS FOKUM FOMUNUNG FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	F0215602	NC

General Provider Information

NPI Number	:	1124414750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLINS FOKUM FOMUNUNG FNP

Provider Business Mailing Address
First Line	:	430 WHITE WATER FALLS DR APT 611
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-5257
Country	:	US
Telephone Number	:	704-258-2936
Fax Number	:

Provider Business Practice Location Address
First Line	:	6608 E W T HARRIS BLVD STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28215-5128
Country	:	US
Telephone Number	:	704-900-7761
Fax Number	:	704-900-8058

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2015
Last Update Date	:	04/10/2015

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