Healthcare Provider Details

I. General information

NPI: 1114710928
Provider Name (Legal Business Name): KORISSA MARIE FAUCETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2025
Last Update Date: 05/24/2025
Certification Date: 05/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 N U ST
FRESNO CA
93701-2438
US

IV. Provider business mailing address

931 W UNIVERSITY AVE APT C
FRESNO CA
93705-4965
US

V. Phone/Fax

Practice location:
  • Phone: 559-445-9094
  • Fax:
Mailing address:
  • Phone: 559-265-0389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: