Healthcare Provider Details

I. General information

NPI: 1104520360
Provider Name (Legal Business Name): GABRIELLE DOMENICA FAZIO FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 BOW POINTE DR STE 120
CLARKSTON MI
48346-3199
US

IV. Provider business mailing address

5701 BOW POINTE DR STE 120
CLARKSTON MI
48346-3199
US

V. Phone/Fax

Practice location:
  • Phone: 248-922-6880
  • Fax:
Mailing address:
  • Phone: 248-922-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704326001
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: