Healthcare Provider Details

I. General information

NPI: 1912330549
Provider Name (Legal Business Name): GAIL CARMEN FAUST NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 26TH ST STE 202
LAFAYETTE IN
47904-2856
US

IV. Provider business mailing address

415 N 26TH ST STE 201
LAFAYETTE IN
47904-2856
US

V. Phone/Fax

Practice location:
  • Phone: 765-607-2001
  • Fax: 765-607-2002
Mailing address:
  • Phone: 765-446-6549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number17861
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71004758A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number71004758A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: