Healthcare Provider Details

I. General information

NPI: 1629775739
Provider Name (Legal Business Name): DIANA LYNN FANNO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2023
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 GRUBB RD # A
MC KEAN PA
16426-1066
US

IV. Provider business mailing address

101 PEMBROKE CT
GREENSBURG PA
15601-6404
US

V. Phone/Fax

Practice location:
  • Phone: 724-396-1510
  • Fax: 724-972-4627
Mailing address:
  • Phone: 724-396-1510
  • Fax: 724-972-4627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW139771
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: