Healthcare Provider Details

I. General information

NPI: 1134656291
Provider Name (Legal Business Name): LANA ELAINE FANSON CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LANA FANOUS SLP

II. Dates (important events)

Enumeration Date: 05/18/2017
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 RONALD REAGAN BLVD STE 220
JOHNSTOWN CO
80534-6503
US

IV. Provider business mailing address

3100 REMINGTON ST
FORT COLLINS CO
80525-2602
US

V. Phone/Fax

Practice location:
  • Phone: 970-669-1639
  • Fax: 970-669-1768
Mailing address:
  • Phone: 970-266-8380
  • Fax: 970-266-8495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP.0003182
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: