Healthcare Provider Details

I. General information

NPI: 1396891826
Provider Name (Legal Business Name): GEORGENE A FANOUS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 BRAINARD ROAD
HIGHLAND HTS. OH
44143
US

IV. Provider business mailing address

6019 BELMERE DR
PARMA OH
44129-5102
US

V. Phone/Fax

Practice location:
  • Phone: 440-995-4500
  • Fax: 440-995-4585
Mailing address:
  • Phone: 440-885-5623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-06103
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: