Provider Demographics
NPI:1689355687
Name:FAJKUS, ALISA BETH (CNM)
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:BETH
Last Name:FAJKUS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 CROWN DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-2548
Mailing Address - Country:US
Mailing Address - Phone:660-627-5757
Mailing Address - Fax:
Practice Address - Street 1:402 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3407
Practice Address - Country:US
Practice Address - Phone:660-665-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013025730163WX0003X
MO2024026678367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient