Provider Demographics
NPI:1417234147
Name:FAZIO, KRISTIN TROUT (APRN, CNM)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:TROUT
Last Name:FAZIO
Suffix:
Gender:F
Credentials:APRN, CNM
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:NICOLE
Other - Last Name:TROUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7130
Mailing Address - Fax:239-343-7185
Practice Address - Street 1:9800 S HEALTHPARK DR STE 205
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3630
Practice Address - Country:US
Practice Address - Phone:239-343-7130
Practice Address - Fax:239-343-7185
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9268943367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004323400Medicaid