Individual
KRISTEN CONWAY FAKES
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1104 E GRACE ST, RENSSELAER, IN 47978-3211
(219) 866-5141
(218) 866-2070
Mailing address
PO BOX 781076, DETROIT, MI 48278-1076
(317) 528-4800
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
28240075A
IN
363LG0600X
Gerontology Nurse Practitioner
Primary
71014561A
IN
Other
Enumeration date
09/01/2023
Last updated
12/18/2023
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