Provider Demographics
NPI:1932646502
Name:FASSU SIANKAM, LINE ORNELLA
Entity Type:Individual
Prefix:
First Name:LINE ORNELLA
Middle Name:
Last Name:FASSU SIANKAM
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 1:205 E UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6821
Mailing Address - Country:US
Mailing Address - Phone:512-994-1933
Mailing Address - Fax:
Practice Address - Street 1:2423 WILLIAMS DR STE 105
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3200
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA760801835P1300X
TX623501835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No1835P1300XPharmacy Service ProvidersPharmacistPsychiatric