Provider Demographics
NPI:1669081170
Name:FUJAMADE, EMMANUELLA
Entity type:Individual
Prefix:
First Name:EMMANUELLA
Middle Name:
Last Name:FUJAMADE
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 1:1450 N STATE HIGHWAY 360 APT 263
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-4131
Mailing Address - Country:US
Mailing Address - Phone:469-493-5471
Mailing Address - Fax:
Practice Address - Street 1:1450 N STATE HIGHWAY 360 APT 263
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-4131
Practice Address - Country:US
Practice Address - Phone:469-493-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1002614163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse