Healthcare Provider Details

I. General information

NPI: 1124676218
Provider Name (Legal Business Name): FASIKA T ENYEW FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2019
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 ATLANTA HWY
GAINESVILLE GA
30504-5948
US

IV. Provider business mailing address

314 CALSTONE DR
ALLEN TX
75013-2975
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-0670
  • Fax:
Mailing address:
  • Phone: 972-837-7323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number214850
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: