Healthcare Provider Details

I. General information

NPI: 1588050488
Provider Name (Legal Business Name): MISS NAOMI RUTH FAWCETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 W SEMANDS ST
CONROE TX
77301-1643
US

IV. Provider business mailing address

1009 W SEMANDS ST
CONROE TX
77301-1643
US

V. Phone/Fax

Practice location:
  • Phone: 936-203-6047
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number609
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number609
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: