=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649649096
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILLIAN PATRICIA FAIS M.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2015
-----------------------------------------------------
Last Update Date | 09/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26 JOSEPHINE LANE
-----------------------------------------------------
City | FORT SALONGA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-896-1217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 JOSEPHINE LANE
-----------------------------------------------------
City | FORT SALONGA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-896-1217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 645E23829
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------