MEDICARE: EDITH FAVA

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	235Z00000X	Speech-Language Pathologist	SP#3282	AR

General Provider Information

NPI Number	:	1477924041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDITH FAVA

Provider Business Mailing Address
First Line	:	PO BOX 1052
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38702-1052
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1659 S HIGHWAY 65 82
Second Line	:
City	:	LAKE VILLAGE
State	:	AR
Zip	:	71653-1661
Country	:	US
Telephone Number	:	870-265-4191
Fax Number	:

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

Provider Enumeration Date	:	10/08/2015
Last Update Date	:	09/27/2016

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Directions to “ EDITH FAVA ” Practice Location

Language	Start Address	Practice Location

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