Provider Demographics
NPI:1376233502
Name:FASUE, VALARIE BELLAH
Entity Type:Individual
Prefix:
First Name:VALARIE
Middle Name:BELLAH
Last Name:FASUE
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 1:1783 HIGHWAY 42 N
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4725
Mailing Address - Country:US
Mailing Address - Phone:678-759-0420
Mailing Address - Fax:
Practice Address - Street 1:1783 HIGHWAY 42 N
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4725
Practice Address - Country:US
Practice Address - Phone:678-759-0420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No174400000XOther Service ProvidersSpecialist