Healthcare Provider Details

I. General information

NPI: 1255258232
Provider Name (Legal Business Name): ALEXANDRIA ROSE FANNING OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N BALDWIN AVE
MARION IN
46952-1929
US

IV. Provider business mailing address

14750 SILT WAY APT 306
NOBLESVILLE IN
46062-9464
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-6148
  • Fax:
Mailing address:
  • Phone: 765-721-7536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004682A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: