Basic Information
| Provider Information | |||||||||
| NPI: | 1356568612 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONOKALAFI | ||||||||
| FirstName: | LESILA | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | TCM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2046 ADAMS AVE REAR 3 | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844010521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013945733 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 237 26TH ST | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844013105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016253700 | ||||||||
| FaxNumber: | 8016253690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 876000308007 | 05 | UT | MEDICAID |