Healthcare Provider Details

I. General information

NPI: 1336914316
Provider Name (Legal Business Name): LISA KAREN FANNON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6708 64TH PL E
BRADENTON FL
34203-8044
US

IV. Provider business mailing address

6708 64TH PL E
BRADENTON FL
34203-8044
US

V. Phone/Fax

Practice location:
  • Phone: 276-698-4325
  • Fax:
Mailing address:
  • Phone: 276-698-4325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024186481
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN11041852
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: