Healthcare Provider Details

I. General information

NPI: 1750598074
Provider Name (Legal Business Name): JESSICA DARLENE FANNIN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 6TH ST
PORTSMOUTH OH
45662-4030
US

IV. Provider business mailing address

1228 MILLDALE RD
PORTSMOUTH OH
45662-8700
US

V. Phone/Fax

Practice location:
  • Phone: 740-876-8290
  • Fax: 740-529-1205
Mailing address:
  • Phone: 740-876-8290
  • Fax: 740-529-1205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number2052118
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: