Provider Demographics
NPI:1699785253
Name:FAUCHER, CHARMAINE L (PA-C)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:L
Last Name:FAUCHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4798 DEER RUN NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152
Mailing Address - Country:US
Mailing Address - Phone:770-794-4423
Mailing Address - Fax:
Practice Address - Street 1:55 WHITCHER STREET
Practice Address - Street 2:SUITE 130
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-590-1078
Practice Address - Fax:770-422-7306
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003932363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP66421Medicare UPIN