Provider Demographics
NPI:1053978288
Name:KANNEH, FATU
Entity type:Individual
Prefix:
First Name:FATU
Middle Name:
Last Name:KANNEH
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 1:3367 REKA ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4227
Mailing Address - Country:US
Mailing Address - Phone:774-329-6072
Mailing Address - Fax:
Practice Address - Street 1:3367 REKA ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4227
Practice Address - Country:US
Practice Address - Phone:774-329-6072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCNA037026376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1606144806Medicaid