Provider Demographics
NPI:1437972098
Name:FUNDAKOWSKI, JOELLA (LMBT)
Entity type:Individual
Prefix:
First Name:JOELLA
Middle Name:
Last Name:FUNDAKOWSKI
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 ENGLISH OAK DR
Mailing Address - Street 2:
Mailing Address - City:BUNNLEVEL
Mailing Address - State:NC
Mailing Address - Zip Code:28323-9080
Mailing Address - Country:US
Mailing Address - Phone:910-624-4867
Mailing Address - Fax:
Practice Address - Street 1:5004 SPRUCE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-2319
Practice Address - Country:US
Practice Address - Phone:910-705-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21286225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist