Provider Demographics
NPI:1215696323
Name:CUSTIS, FAYNE
Entity type:Individual
Prefix:
First Name:FAYNE
Middle Name:
Last Name:CUSTIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E BERRY ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1901
Mailing Address - Country:US
Mailing Address - Phone:765-655-4737
Mailing Address - Fax:
Practice Address - Street 1:2 E BERRY ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1901
Practice Address - Country:US
Practice Address - Phone:765-655-4737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty