Healthcare Provider Details

I. General information

NPI: 1063845832
Provider Name (Legal Business Name): LEWIS DALE FANNON RN, NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2013
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 SHRADER ST
SAN FRANCISCO CA
94117-1015
US

IV. Provider business mailing address

368 FELL ST
SAN FRANCISCO CA
94102-5144
US

V. Phone/Fax

Practice location:
  • Phone: 415-668-4166
  • Fax:
Mailing address:
  • Phone: 415-861-0828
  • Fax: 415-861-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number801999
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number23521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: