Provider Demographics
NPI:1437809316
Name:FAZEKAS-WOOLWINE, NICOLE ALEXANDRA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRA
Last Name:FAZEKAS-WOOLWINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 OAKTREE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-4739
Mailing Address - Country:US
Mailing Address - Phone:571-970-7700
Mailing Address - Fax:
Practice Address - Street 1:717 S HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9023
Practice Address - Country:US
Practice Address - Phone:918-382-3178
Practice Address - Fax:918-382-6789
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program