Provider Demographics
NPI:1841458965
Name:BAYLOR COLLEGE OF MEDICINE
Entity type:Organization
Organization Name:BAYLOR COLLEGE OF MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:COREEN
Authorized Official - Middle Name:VON
Authorized Official - Last Name:FAZAKERLY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, ANP-C
Authorized Official - Phone:713-798-4696
Mailing Address - Street 1:5012 JACKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77096-1507
Mailing Address - Country:US
Mailing Address - Phone:713-664-8862
Mailing Address - Fax:
Practice Address - Street 1:1709 DRYDEN RD
Practice Address - Street 2:750
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2400
Practice Address - Country:US
Practice Address - Phone:713-798-4696
Practice Address - Fax:713-798-3739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX511846261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical