Provider Demographics
NPI:1932479920
Name:FAUSNAUGH, SHERENDA NICOLE (IDMT)
Entity Type:Individual
Prefix:MS
First Name:SHERENDA
Middle Name:NICOLE
Last Name:FAUSNAUGH
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 22495
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5195 S 148TH AVE
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:MI
Practice Address - Zip Code:49421-9546
Practice Address - Country:US
Practice Address - Phone:313-258-3114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians