Provider Demographics
NPI:1164922944
Name:EFUNSHILE, DESOLA MARY (NURSE)
Entity Type:Individual
Prefix:MRS
First Name:DESOLA
Middle Name:MARY
Last Name:EFUNSHILE
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8720 NOONTIDE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-5287
Mailing Address - Country:US
Mailing Address - Phone:240-462-3274
Mailing Address - Fax:
Practice Address - Street 1:5900 BLACKBURN DR
Practice Address - Street 2:
Practice Address - City:JOSHUA
Practice Address - State:TX
Practice Address - Zip Code:76058-5427
Practice Address - Country:US
Practice Address - Phone:240-462-3274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-18
Last Update Date:2018-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX329260164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse