Provider Demographics
NPI:1770781098
Name:FUNDERBURK, TENEIKA CLIFTON
Entity type:Individual
Prefix:MRS
First Name:TENEIKA
Middle Name:CLIFTON
Last Name:FUNDERBURK
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 1:6033 FLORENCE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-6390
Mailing Address - Country:US
Mailing Address - Phone:980-430-5055
Mailing Address - Fax:704-749-8652
Practice Address - Street 1:6033 FLORENCE AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212
Practice Address - Country:US
Practice Address - Phone:980-430-5055
Practice Address - Fax:704-749-8652
Is Sole Proprietor?:No
Enumeration Date:2007-07-08
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC34033747A0650X, 3747P1801X
NC329836376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601520Medicaid