Provider Demographics
NPI:1407466410
Name:FACKELMAN, TRENT J (FNP-C)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:J
Last Name:FACKELMAN
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 KERRI STRUG CV
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-2077
Mailing Address - Country:US
Mailing Address - Phone:210-655-9613
Mailing Address - Fax:
Practice Address - Street 1:8500 VILLAGE DR STE 202
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-5510
Practice Address - Country:US
Practice Address - Phone:210-957-1419
Practice Address - Fax:210-957-1697
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX816398163W00000X
TX1007822363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse