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General NPI Number Information
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NPI Number | 1831914753
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Entity Type | Individual
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Provider Name | NICOLE MARIE FAZIO
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Gender | Female
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Dates
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Enumeration Date | 11/15/2024
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 1450 E VENICE AVE
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City | VENICE
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State | FL
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Zip | 34292-3063
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Country | US
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Telephone | 908-239-3448
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Fax |
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Provider Business Mailing Address
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Address Line | 1849 SADDLEWOOD CIR
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City | PORT CHARLOTTE
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State | FL
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Zip | 33953-5973
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Country | US
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Telephone | 908-239-3448
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT21419
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License Number State | FL
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