Provider Demographics
NPI:1215330360
Name:NFUNDOAK, MANYI JOELLE
Entity type:Individual
Prefix:MRS
First Name:MANYI
Middle Name:JOELLE
Last Name:NFUNDOAK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:MANYI
Other - Middle Name:JOELLE
Other - Last Name:LIKINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2320 E 93RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3909
Mailing Address - Country:US
Mailing Address - Phone:773-967-5805
Mailing Address - Fax:773-967-5808
Practice Address - Street 1:2535 S KING DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4746
Practice Address - Country:US
Practice Address - Phone:312-842-7117
Practice Address - Fax:312-842-6155
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085005132363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant