Provider Demographics
NPI:1053901363
Name:FASUEKOI, YOUNGER (HHA/LNA)
Entity type:Individual
Prefix:
First Name:YOUNGER
Middle Name:
Last Name:FASUEKOI
Suffix:
Gender:F
Credentials:HHA/LNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5190 N 55TH AVE APT 250
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-7543
Mailing Address - Country:US
Mailing Address - Phone:763-283-7679
Mailing Address - Fax:
Practice Address - Street 1:5190 N 55TH AVE APT 250
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7543
Practice Address - Country:US
Practice Address - Phone:763-283-7679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ249313376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20201227124613Medicaid