Basic Information
| Provider Information | |||||||||
| NPI: | 1114680642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLUKER | ||||||||
| FirstName: | VALARIE | ||||||||
| MiddleName: | TYTIANNIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2D DENBN/NDC, PSC 20130 | ||||||||
| Address2: | 315 MCHUGH BLVD | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2D DENBN/NDC, PSC 20130 | ||||||||
| Address2: | 315 MCHUGH BLVD | ||||||||
| City: | CAMP LEJEUNE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104512208 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2021 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 11913 | NC | Y | Dental Providers | Dental Hygienist |
No ID Information.