Healthcare Provider Details

I. General information

NPI: 1063263572
Provider Name (Legal Business Name): FABIENNE FIFY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 03/01/2025
Certification Date: 03/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 I ST
LA PORTE IN
46350-5750
US

IV. Provider business mailing address

1118 W 112TH PL
CHICAGO IL
60643-4518
US

V. Phone/Fax

Practice location:
  • Phone: 708-288-5036
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71015257A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberMF9072769
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: