Basic Information
| Provider Information | |||||||||
| NPI: | 1417904293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAWNS | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2195 HARRODSBURG RD | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236712 | ||||||||
| FaxNumber: | 8593236661 | ||||||||
| Practice Location | |||||||||
| Address1: | 2195 HARRODSBURG RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236371 | ||||||||
| FaxNumber: | 8593236661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 06/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 37312 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2619152 | 05 | OH | MEDICAID | 3810003773 | 05 | WV | MEDICAID | 64068117 | 05 | KY | MEDICAID |