Provider Demographics
NPI:1932922028
Name:FUKOFUKA, MELEKULUKONA TAIESE
Entity type:Individual
Prefix:
First Name:MELEKULUKONA
Middle Name:TAIESE
Last Name:FUKOFUKA
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 1:2900 W LEHMAN AVE APT 358
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3660
Mailing Address - Country:US
Mailing Address - Phone:801-381-1426
Mailing Address - Fax:
Practice Address - Street 1:252 W BROOKLYN AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3024
Practice Address - Country:US
Practice Address - Phone:801-845-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9497303106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty