Healthcare Provider Details

I. General information

NPI: 1093685059
Provider Name (Legal Business Name): MARLEY JANE FANNING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE STE 12A19
NEW YORK NY
10029-7494
US

IV. Provider business mailing address

1112 EDGEWATER CLUB RD
WILMINGTON NC
28411-9355
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone: 910-777-3359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number034650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: