Healthcare Provider Details

I. General information

NPI: 1336929405
Provider Name (Legal Business Name): KRISTINE FASNACHT FUMIA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2023
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

513 MAIN STREET STE 1
MADISON LAKE MN
56063
US

IV. Provider business mailing address

PO BOX 94
MADISON LAKE MN
56063-0094
US

V. Phone/Fax

Practice location:
  • Phone: 507-737-0009
  • Fax:
Mailing address:
  • Phone: 507-373-0009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number240
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number2041
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: