=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871062059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANDACE LYNN FAZIO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2018
-----------------------------------------------------
Last Update Date | 11/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 88 NOTCH HILL RD
-----------------------------------------------------
City | NORTH BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06471-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-315-2319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 NOTCH HILL RD
-----------------------------------------------------
City | NORTH BRANFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06471-1846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------