Provider Demographics
NPI:1326528290
Name:FONDRICK, MAKAYLA LEEANN
Entity Type:Individual
Prefix:
First Name:MAKAYLA
Middle Name:LEEANN
Last Name:FONDRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CUNNINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:TX
Mailing Address - Zip Code:77657-9589
Mailing Address - Country:US
Mailing Address - Phone:409-338-4355
Mailing Address - Fax:
Practice Address - Street 1:3330 FANNIN ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3801
Practice Address - Country:US
Practice Address - Phone:409-832-3304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide