Basic Information
| Provider Information | |||||||||
| NPI: | 1487615787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAZENBAKER | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3276 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477313276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124730181 | ||||||||
| FaxNumber: | 8124735822 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 FREDERICA ST STE 5 | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 423016085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2702979075 | ||||||||
| FaxNumber: | 2702979077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35999 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6402415100 | 05 | KY | MEDICAID | 7570 | 01 | KY | COMMONWEALTH BIOMEDICAL RESEARCH GROUP PTAN | OTHER | 35999 | 01 | KY | KY MEDICAL LICENSE NUMBER | OTHER | 000000811728 | 01 | KY | ANTHEM | OTHER |