Provider Demographics
NPI:1104520360
Name:FAZIO, GABRIELLE DOMENICA (FNP-BC)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:DOMENICA
Last Name:FAZIO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3199
Mailing Address - Country:US
Mailing Address - Phone:248-922-6880
Mailing Address - Fax:
Practice Address - Street 1:5701 BOW POINTE DR STE 120
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3199
Practice Address - Country:US
Practice Address - Phone:248-922-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-29
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704326001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily