Provider Demographics
NPI:1780317859
Name:FUNK, EMMA CHRISTINE
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:CHRISTINE
Last Name:FUNK
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 1:27866 AVENIDA ARMIJO
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-4024
Mailing Address - Country:US
Mailing Address - Phone:949-573-3812
Mailing Address - Fax:
Practice Address - Street 1:298 HOWARD ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8313
Practice Address - Country:US
Practice Address - Phone:508-879-2250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4369539390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty