Healthcare Provider Details

I. General information

NPI: 1003467879
Provider Name (Legal Business Name): SUNNY MAKOLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST STE 280
GARDENA CA
90248-4305
US

IV. Provider business mailing address

2550 W UNION HILLS DR
PHOENIX AZ
85027-5163
US

V. Phone/Fax

Practice location:
  • Phone: 877-515-8113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number250872
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number844501
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: