Provider Demographics
NPI:1386041150
Name:FUNDERBURK, FALLON (BSN, RN, CNOR, RNFA)
Entity Type:Individual
Prefix:MRS
First Name:FALLON
Middle Name:
Last Name:FUNDERBURK
Suffix:
Gender:F
Credentials:BSN, RN, CNOR, RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 RUE DE FREJUS
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4993
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 KALISTE SALOOM RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5705
Practice Address - Country:US
Practice Address - Phone:337-769-4241
Practice Address - Fax:337-769-4249
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-22
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN105855163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant