Provider Demographics
NPI:1356051783
Name:BOUGUYON, FAYNE A
Entity type:Individual
Prefix:
First Name:FAYNE
Middle Name:A
Last Name:BOUGUYON
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 1:2606 CHINKAPIN LN
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-1611
Mailing Address - Country:US
Mailing Address - Phone:214-476-1719
Mailing Address - Fax:
Practice Address - Street 1:1719 ANALOG DR
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-1944
Practice Address - Country:US
Practice Address - Phone:214-476-1719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 225800000X, 2255A2300X
TXMT042244225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No171400000XOther Service ProvidersHealth & Wellness Coach
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist