Provider Demographics
NPI:1487615787
Name:FAZENBAKER, STACEY B (M D)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:B
Last Name:FAZENBAKER
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:812-473-5822
Practice Address - Street 1:3333 FREDERICA ST STE 5
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6085
Practice Address - Country:US
Practice Address - Phone:270-297-9075
Practice Address - Fax:270-297-9077
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2022-03-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY35999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6402415100Medicaid
KY7570OtherCOMMONWEALTH BIOMEDICAL RESEARCH GROUP PTAN
KY35999OtherKY MEDICAL LICENSE NUMBER
KY000000811728OtherANTHEM
KY7570OtherCOMMONWEALTH BIOMEDICAL RESEARCH GROUP PTAN