Provider Demographics
NPI:1104008549
Name:FAI, EMMANUEL TATAH (LPN)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:TATAH
Last Name:FAI
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 KING ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1919
Mailing Address - Country:US
Mailing Address - Phone:585-328-6108
Mailing Address - Fax:
Practice Address - Street 1:43 VICK PARK A APT 5
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-2125
Practice Address - Country:US
Practice Address - Phone:585-436-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291510-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY291510-1OtherLPN LICENSE