Healthcare Provider Details

I. General information

NPI: 1053901363
Provider Name (Legal Business Name): YOUNGER FASUEKOI HHA/LNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5190 N 55TH AVE APT 250
GLENDALE AZ
85301-7543
US

IV. Provider business mailing address

5190 N 55TH AVE APT 250
GLENDALE AZ
85301-7543
US

V. Phone/Fax

Practice location:
  • Phone: 763-283-7679
  • Fax:
Mailing address:
  • Phone: 763-283-7679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number249313
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: