Healthcare Provider Details

I. General information

NPI: 1386970515
Provider Name (Legal Business Name): MICHAEL ANTON FACKLMANN CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2009
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD SUITE 300
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

1001 BLYTHE BLVD SUITE 300
CHARLOTTE NC
28203-5866
US

V. Phone/Fax

Practice location:
  • Phone: 704-373-0212
  • Fax: 704-373-2626
Mailing address:
  • Phone: 704-373-0212
  • Fax: 704-373-2626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number0001206848
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: