Provider Demographics
NPI:1417293788
Name:BAESEMANN, FAWN M (RN)
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:M
Last Name:BAESEMANN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-8869
Mailing Address - Country:US
Mailing Address - Phone:802-748-5814
Mailing Address - Fax:
Practice Address - Street 1:245 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-8869
Practice Address - Country:US
Practice Address - Phone:802-748-5814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0260024768163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse