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General NPI Number Information
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NPI Number | 1093685059
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Entity Type | Individual
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Provider Name | MARLEY JANE FANNING
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Gender | Female
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Dates
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Enumeration Date | 11/06/2025
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Last Update Date | 11/06/2025
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Provider Practice Location Address
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Address Line | 1901 1ST AVE STE 12A19
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City | NEW YORK
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State | NY
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Zip | 10029-7494
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Country | US
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Telephone | 212-423-6262
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Fax |
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Provider Business Mailing Address
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Address Line | 1112 EDGEWATER CLUB RD
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City | WILMINGTON
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State | NC
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Zip | 28411-9355
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Country | US
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Telephone | 910-777-3359
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 034650
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License Number State | NY
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