Individual
KENNETH ELAD FONGUCK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1 CVS DR, WOONSOCKET, RI 02895-6146
(402) 419-6291
Mailing address
3768 SOUTHFIELD CT, LOGANVILLE, GA 30052-4863
(404) 643-9031
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
296175
GA
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
APRN-NP296175
GA
Other
Enumeration date
12/18/2020
Last updated
03/19/2026
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