MEDICARE: PENNY FANNING FNP

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	363L00000X	Nurse Practitioner	22420	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912566365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENNY FANNING FNP

Provider Business Mailing Address
First Line	:	PO BOX 751874
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1874
Country	:	US
Telephone Number	:	843-402-5200
Fax Number	:	843-402-5296

Provider Business Practice Location Address
First Line	:	2910 TRICOM ST STE 100
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-9351
Country	:	US
Telephone Number	:	843-572-9211
Fax Number	:	843-572-0457

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

Provider Enumeration Date	:	06/10/2019
Last Update Date	:	10/01/2025

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