Basic Information
| Provider Information | |||||||||
| NPI: | 1649807173 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAWCETT | ||||||||
| FirstName: | CHARLOTTE | ||||||||
| MiddleName: | REGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 322 CAUSEWAY DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | WRIGHTSVILLE BEACH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284801981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047268741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5246 BRITTANY DR | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708089136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257574210 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2020 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.