Healthcare Provider Details

I. General information

NPI: 1700558913
Provider Name (Legal Business Name): NICOLE FAHS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 02/09/2023
Certification Date: 02/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TUSKEGEE BLVD # DE19902
DOVER AFB DE
19902-5003
US

IV. Provider business mailing address

5955 ZEAMER AVE
ELMENDORF AFB AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 302-677-2574
  • Fax:
Mailing address:
  • Phone: 907-580-2778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number61224496
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: