Healthcare Provider Details

I. General information

NPI: 1568564383
Provider Name (Legal Business Name): JOHNNIE LAURAETTA FANNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 MERTON MINTER ST
SAN ANTONIO TX
78229-4404
US

IV. Provider business mailing address

707 SINGING WIND DR
SAN ANTONIO TX
78227-1028
US

V. Phone/Fax

Practice location:
  • Phone: 210-617-5300
  • Fax: 210-949-3452
Mailing address:
  • Phone: 210-617-5300
  • Fax: 210-949-3452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374T00000X
TaxonomyReligious Nonmedical Nursing Personnel
License Number221594
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: