Provider Demographics
NPI:1003467879
Name:MAKOLO, SUNNY
Entity type:Individual
Prefix:
First Name:SUNNY
Middle Name:
Last Name:MAKOLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W UNION HILLS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5163
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2405 STONEWALL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-3349
Practice Address - Country:US
Practice Address - Phone:903-454-3300
Practice Address - Fax:903-454-3307
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ250872363LP0808X
TX844501363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health