MEDICARE: LISA FANNIN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1346850245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA FANNIN

Provider Business Mailing Address
First Line	:	79 ANDOVER LN
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25320-7770
Country	:	US
Telephone Number	:	304-542-5955
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 ANDOVER LN
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25320-7770
Country	:	US
Telephone Number	:	304-542-5955
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2020
Last Update Date	:	05/04/2022

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Directions to “ LISA FANNIN ” Practice Location

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