Healthcare Provider Details

I. General information

NPI: 1376626556
Provider Name (Legal Business Name): JOY R FACKENTHALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOY R GUDERIAN MD

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7205 265TH ST NW
STANWOOD WA
98292-6221
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 360-629-1504
  • Fax:
Mailing address:
  • Phone: 425-258-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37986
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: