Provider Demographics
NPI:1376626556
Name:FACKENTHALL, JOY R (MD)
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:R
Last Name:FACKENTHALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:R
Other - Last Name:GUDERIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-258-3900
Mailing Address - Fax:
Practice Address - Street 1:7205 265TH ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6221
Practice Address - Country:US
Practice Address - Phone:360-629-1504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA37986207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1008993Medicaid
WA37986OtherLICENSE
WA1008993Medicaid