Healthcare Provider Details

I. General information

NPI: 1922094937
Provider Name (Legal Business Name): DAVID FAWKS ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 02/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 E VENICE AVE SUITE 204
VENICE FL
34292-3191
US

IV. Provider business mailing address

1790 E VENICE AVE SUITE 204
VENICE FL
34292-3191
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-8884
  • Fax: 941-488-5554
Mailing address:
  • Phone: 941-488-8884
  • Fax: 941-488-5554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP1799382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: