Provider Demographics
NPI:1497528210
Name:FONUA, LUPI
Entity Type:Individual
Prefix:
First Name:LUPI
Middle Name:
Last Name:FONUA
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 1:14094 S GRAND VIEW PEAK CIR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1769
Mailing Address - Country:US
Mailing Address - Phone:831-238-2493
Mailing Address - Fax:
Practice Address - Street 1:14094 S GRAND VIEW PEAK CIR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-1769
Practice Address - Country:US
Practice Address - Phone:831-238-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program