MEDICARE: COURTNEY ELYSE FEZZEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0222X	Critical Care Pediatric Nurse Practitioner	4704268781	MI

General Provider Information

NPI Number	:	1073935383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COURTNEY ELYSE FEZZEY

Provider Business Mailing Address
First Line	:	3200 E LAFAYETTE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3812
Country	:	US
Telephone Number	:	313-567-0534
Fax Number	:	313-567-0560

Provider Business Practice Location Address
First Line	:	3200 E LAFAYETTE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3812
Country	:	US
Telephone Number	:	313-567-0534
Fax Number	:	313-567-0560

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/07/2014
Last Update Date	:	02/08/2019

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Directions to “ COURTNEY ELYSE FEZZEY ” Practice Location

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