Provider Demographics
NPI:1487238218
Name:CHUKKAN, FAMINA
Entity type:Individual
Prefix:
First Name:FAMINA
Middle Name:
Last Name:CHUKKAN
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 1:1010 GABLES LN
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-5022
Mailing Address - Country:US
Mailing Address - Phone:404-952-9546
Mailing Address - Fax:
Practice Address - Street 1:1010 GABLES LN
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-5022
Practice Address - Country:US
Practice Address - Phone:404-952-9546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-21-166081106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician