Healthcare Provider Details

I. General information

NPI: 1679403190
Provider Name (Legal Business Name): FEDELIS FONDUNGALLAH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: THERESA FONDUNGALLAH

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11851 W KINDERMAN DR
AVONDALE AZ
85323-9115
US

IV. Provider business mailing address

11851 W KINDERMAN DR
AVONDALE AZ
85323-9115
US

V. Phone/Fax

Practice location:
  • Phone: 651-235-3994
  • Fax:
Mailing address:
  • Phone: 651-235-3994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: