=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497595540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATRINA LEIGH FASEN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 12/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 UNIVERSITY PKWY STE 1550
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29801-6838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-649-7535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 460 CLEMSON RD
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229-7925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-840-3351
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 28972
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------