Healthcare Provider Details

I. General information

NPI: 1053670323
Provider Name (Legal Business Name): GWENDOLYN N. FACISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 ELMWOOD CT B
EL PASO TX
79932
US

IV. Provider business mailing address

P.O. BOX 220696
EL PASO TX
79913
US

V. Phone/Fax

Practice location:
  • Phone: 561-713-6032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: