Healthcare Provider Details

I. General information

NPI: 1275415580
Provider Name (Legal Business Name): ADAM THOMAS FANNIN MSN, MHA, APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2025
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE STE 205
CHARLESTON WV
25304-1228
US

IV. Provider business mailing address

3417 VIRGINIA AVE SE
CHARLESTON WV
25304-1308
US

V. Phone/Fax

Practice location:
  • Phone: 740-395-6011
  • Fax:
Mailing address:
  • Phone: 740-395-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number108310
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number108310
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: