Provider Demographics
NPI:1245798214
Name:WONDIFRAW, FASICA
Entity Type:Individual
Prefix:
First Name:FASICA
Middle Name:
Last Name:WONDIFRAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FASICA
Other - Middle Name:
Other - Last Name:ADMASU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP, APRN
Mailing Address - Street 1:1218 W MCDERMOTT DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6304
Mailing Address - Country:US
Mailing Address - Phone:972-390-9000
Mailing Address - Fax:
Practice Address - Street 1:1218 W MCDERMOTT DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6304
Practice Address - Country:US
Practice Address - Phone:972-390-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP139847363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily