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General NPI Number Information
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NPI Number | 1558598292
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Entity Type | Individual
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Provider Name | MICHELLE FANOUS D.O.
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Gender | Female
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Dates
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Enumeration Date | 06/21/2009
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 425 JACK MARTIN BLVD
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City | BRICK
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State | NJ
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Zip | 08724-7732
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Country | US
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Telephone | 732-397-8630
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Fax | 201-365-5287
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Provider Business Mailing Address
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Address Line | 14 ALEXIS DR
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City | FARMINGDALE
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State | NJ
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Zip | 07727-3648
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Country | US
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Telephone | 732-397-8630
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Fax | 732-397-8630
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | OT012883&OS015355
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 25MB09538400
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | OS015355&OT012883
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 25MB09538400
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License Number State | NJ
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