Provider Demographics
NPI:1447062443
Name:FUQUA, JOHNNA
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:
Last Name:FUQUA
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 1:300 N DOGWOOD ST APT A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-9440
Mailing Address - Country:US
Mailing Address - Phone:573-629-8106
Mailing Address - Fax:
Practice Address - Street 1:12416 FARNAM ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2333
Practice Address - Country:US
Practice Address - Phone:573-629-8106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-25
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child