Provider Demographics
NPI:1629618624
Name:FANKAM, ELIANE SANDRINE TUECHE
Entity Type:Individual
Prefix:
First Name:ELIANE SANDRINE
Middle Name:TUECHE
Last Name:FANKAM
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 1:4401 SADDLE CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2206
Mailing Address - Country:US
Mailing Address - Phone:301-385-7756
Mailing Address - Fax:
Practice Address - Street 1:4401 SADDLE CREEK WAY
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-2206
Practice Address - Country:US
Practice Address - Phone:301-385-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR199673363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health