Provider Demographics
NPI:1053954503
Name:FAZIL, FARIAHH (FNP-BC)
Entity type:Individual
Prefix:
First Name:FARIAHH
Middle Name:
Last Name:FAZIL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:FARIA
Other - Middle Name:F
Other - Last Name:IMDAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 955860
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-2551
Mailing Address - Country:US
Mailing Address - Phone:636-498-5944
Mailing Address - Fax:
Practice Address - Street 1:2 GOOD SAMARITAN WAY STE 235
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2476
Practice Address - Country:US
Practice Address - Phone:618-899-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019228363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209019228OtherLICENSE