Provider Demographics
NPI:1063833622
Name:FRASER, FAITH (REV)
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:
Last Name:FRASER
Suffix:
Gender:F
Credentials:REV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5390 LOCH LOMOND RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-9049
Mailing Address - Country:US
Mailing Address - Phone:901-321-5511
Mailing Address - Fax:
Practice Address - Street 1:5390 LOCH LOMOND RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-9049
Practice Address - Country:US
Practice Address - Phone:901-321-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI206040OtherSTATE CERTIFICATION
TN00145595OtherSTATE CERTIFICATION