Healthcare Provider Details

I. General information

NPI: 1548732092
Provider Name (Legal Business Name): COURTNEY NICOLE FAZEL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MOHAWK STREET
BROWNSVILLE KY
42210
US

IV. Provider business mailing address

1425 HILEY SPENCER RD
SCOTTSVILLE KY
42164
US

V. Phone/Fax

Practice location:
  • Phone: 270-597-2155
  • Fax:
Mailing address:
  • Phone: 270-618-0437
  • Fax: 270-597-3811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3012884
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: