Provider Demographics
NPI:1871717942
Name:FAZAKERLY, COREEN VON (NP)
Entity type:Individual
Prefix:
First Name:COREEN
Middle Name:VON
Last Name:FAZAKERLY
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:2 GREENWAY PLZ
Mailing Address - Street 2:SUITE 910
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0297
Mailing Address - Country:US
Mailing Address - Phone:713-798-1750
Mailing Address - Fax:713-798-1144
Practice Address - Street 1:6620 MAIN ST
Practice Address - Street 2:SUITE 1350
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2348
Practice Address - Country:US
Practice Address - Phone:713-798-4696
Practice Address - Fax:713-798-3739
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2011-01-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX511846363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB110173Medicare PIN
TXP00871461Medicare PIN
TX8K6195Medicare PIN