Provider Demographics
NPI:1154964617
Name:NEZIREVIC, FATIMA (KCSA)
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:
Last Name:NEZIREVIC
Suffix:
Gender:F
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 SCOTTSVILLE RD B2 PMB 397
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-781-4828
Mailing Address - Fax:
Practice Address - Street 1:1945 SCOTTSVILLE RD B2 PMB 397
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104
Practice Address - Country:US
Practice Address - Phone:270-781-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA343246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant