Provider Demographics
NPI:1932862653
Name:DUKULY, FANTA
Entity Type:Individual
Prefix:
First Name:FANTA
Middle Name:
Last Name:DUKULY
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 1:802 45TH ST NE APT 12-102
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-1405
Mailing Address - Country:US
Mailing Address - Phone:206-823-4585
Mailing Address - Fax:
Practice Address - Street 1:802 45TH ST NE APT 12-102
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-1405
Practice Address - Country:US
Practice Address - Phone:206-823-4585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider