Healthcare Provider Details

I. General information

NPI: 1790435543
Provider Name (Legal Business Name): JAMIE FANNIN MS, ACSM-CEP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 03/25/2022
Certification Date: 03/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E MAXWELL ST STE 103
LEXINGTON KY
40508-2621
US

IV. Provider business mailing address

135 E MAXWELL ST STE 103
LEXINGTON KY
40508-2621
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5424
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: