Healthcare Provider Details

I. General information

NPI: 1043318991
Provider Name (Legal Business Name): KIMBERLY R FANNIN - TRISLER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2106 LOOP RD # C
WINNSBORO LA
71295-3344
US

IV. Provider business mailing address

1154 LOGAN SEWELL DR
VIDALIA LA
71373-3342
US

V. Phone/Fax

Practice location:
  • Phone: 318-435-4571
  • Fax: 318-435-3842
Mailing address:
  • Phone: 318-336-8166
  • Fax: 318-336-8169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number085994
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: