Healthcare Provider Details

I. General information

NPI: 1376721852
Provider Name (Legal Business Name): MRS. ANDREA NICOLE FACKLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 02/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 NEW GLENDALE RD LINCOLN TRAIL DISTRICT HEALTH DEPT
ELIZABETHTOWN KY
42702-2609
US

IV. Provider business mailing address

PO BOX 2609
ELIZABETHTOWN KS
42702-2609
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-1601
  • Fax: 270-765-7274
Mailing address:
  • Phone: 270-769-1601
  • Fax: 270-765-7274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: