Healthcare Provider Details

I. General information

NPI: 1306830146
Provider Name (Legal Business Name): CATHY JO FANNING DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 ALMONDRIDGE DR
RURAL HALL NC
27045
US

IV. Provider business mailing address

PO BOX 1267
MOUNT AIRY NC
27030-1267
US

V. Phone/Fax

Practice location:
  • Phone: 336-969-1185
  • Fax: 336-969-1186
Mailing address:
  • Phone: 336-786-4522
  • Fax: 336-969-1186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010-00559
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: