Healthcare Provider Details

I. General information

NPI: 1356457147
Provider Name (Legal Business Name): NICOLE MARIE FAVA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 VICTORIA RD
ASHEVILLE NC
28801-4811
US

IV. Provider business mailing address

623 HAW CREEK MEWS PL
ASHEVILLE NC
28805-7902
US

V. Phone/Fax

Practice location:
  • Phone: 828-252-7331
  • Fax: 828-253-1123
Mailing address:
  • Phone: 919-619-4837
  • Fax: 828-253-1123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-07893
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: