Healthcare Provider Details

I. General information

NPI: 1033670450
Provider Name (Legal Business Name): BETHAN CLARE FANNING MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 BELLE HAVEN RD STE 110
ALEXANDRIA VA
22307-1201
US

IV. Provider business mailing address

1451 BELLE HAVEN RD STE 110
ALEXANDRIA VA
22307-1201
US

V. Phone/Fax

Practice location:
  • Phone: 703-765-6093
  • Fax:
Mailing address:
  • Phone: 703-765-6093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101275377
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: