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General NPI Number Information
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NPI Number | 1366193377
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Entity Type | Individual
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Provider Name | JONATHAN MICHAEL FANSLER NP
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Gender | Male
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Dates
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Enumeration Date | 01/11/2022
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Last Update Date | 09/19/2025
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Provider Practice Location Address
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Address Line | 2500 N DETROIT ST
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City | LAGRANGE
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State | IN
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Zip | 46761-1158
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Country | US
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Telephone | 260-463-2133
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Fax | 260-463-3775
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Provider Business Mailing Address
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Address Line | PO BOX 236
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City | LAGRANGE
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State | IN
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Zip | 46761-0236
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Country | US
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Telephone | 260-463-2133
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Fax | 260-463-3775
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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 | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71012167A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 28234112A
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License Number State | IN
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