Provider Demographics
NPI:1689355687
Name:FAJKUS, ALISA BETH
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:BETH
Last Name:FAJKUS
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 1:915 E LINE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4115
Mailing Address - Country:US
Mailing Address - Phone:660-342-1896
Mailing Address - Fax:
Practice Address - Street 1:915 E LINE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4115
Practice Address - Country:US
Practice Address - Phone:660-342-1896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013025730163WX0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient