Provider Demographics
NPI:1821754979
Name:FAKOURI, KAITLYN ELIZABETH (FNP-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:FAKOURI
Suffix:
Gender:F
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 1:11776 PLATO WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8107
Mailing Address - Country:US
Mailing Address - Phone:225-333-0806
Mailing Address - Fax:
Practice Address - Street 1:3441 MARYSVILLE BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-4512
Practice Address - Country:US
Practice Address - Phone:916-737-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner