Provider Demographics
NPI:1255569612
Name:FAUGHT, JANICE RENEE (IDMT)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:RENEE
Last Name:FAUGHT
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 1:2243 IRONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:KS
Mailing Address - Zip Code:67037-3150
Mailing Address - Country:US
Mailing Address - Phone:316-789-5872
Mailing Address - Fax:
Practice Address - Street 1:57950 LEAVENWORTH ST BLDG 250
Practice Address - Street 2:
Practice Address - City:MCCONNELL AFB
Practice Address - State:KS
Practice Address - Zip Code:67221-3506
Practice Address - Country:US
Practice Address - Phone:316-759-5022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians