Provider Demographics
NPI:1780937813
Name:MAKONYONGA, FADZAI
Entity type:Individual
Prefix:
First Name:FADZAI
Middle Name:
Last Name:MAKONYONGA
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 1:100 CAPITOLA DRIVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713
Mailing Address - Country:US
Mailing Address - Phone:919-474-6400
Mailing Address - Fax:919-474-6401
Practice Address - Street 1:100 CAPITOLA DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-4496
Practice Address - Country:US
Practice Address - Phone:919-474-6400
Practice Address - Fax:919-474-6401
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC58-1716970Medicaid