Healthcare Provider Details

I. General information

NPI: 1982340162
Provider Name (Legal Business Name): CHRISTOPHER M FACKELMANN APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

38768 COUNTRY CLUB DR
AVON OH
44011-5279
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-3722
  • Fax:
Mailing address:
  • Phone: 440-382-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.367836
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0027996
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: