Basic Information
| Provider Information | |||||||||
| NPI: | 1336884709 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOFANAH | ||||||||
| FirstName: | FATIMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2616 S SYLMAR ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191422125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156079832 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 LOGAN SQ STE 300 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191032733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889222843 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2022 | ||||||||
| LastUpdateDate: | 04/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | PA | Y |
No ID Information.