Healthcare Provider Details

I. General information

NPI: 1265098487
Provider Name (Legal Business Name): KRISTIN MARSHALL FAJER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23297 NW 8TH PL
NEWBERRY FL
32669-2673
US

IV. Provider business mailing address

PO BOX 100277
GAINESVILLE FL
32610-0277
US

V. Phone/Fax

Practice location:
  • Phone: 352-284-7412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112601
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: