Healthcare Provider Details

I. General information

NPI: 1194638668
Provider Name (Legal Business Name): IRIS ELLEN FANNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6653 WEAVER RD STE 106
ROCKFORD IL
61114-8068
US

IV. Provider business mailing address

6653 WEAVER RD STE 106
ROCKFORD IL
61114-8068
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-7301
  • Fax: 779-235-9660
Mailing address:
  • Phone: 815-599-7300
  • Fax: 779-235-9660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number150.131791
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: