Healthcare Provider Details

I. General information

NPI: 1467448654
Provider Name (Legal Business Name): SUSAN M. FAZEKAS FPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 PAUL REVERE DR
CHESTERTON IN
46304-9371
US

IV. Provider business mailing address

259 PAUL REVERE DR
CHESTERTON IN
46304-9371
US

V. Phone/Fax

Practice location:
  • Phone: 219-405-6779
  • Fax:
Mailing address:
  • Phone: 219-405-6779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000803A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: