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General NPI Number Information
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NPI Number | 1699568444
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Entity Type | Individual
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Provider Name | MATTHEW CLARK FANNING PMHNP-BC
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Gender | Male
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Dates
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Enumeration Date | 05/26/2025
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Last Update Date | 05/26/2025
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Provider Practice Location Address
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Address Line | 1401 GREENSBORO AVE
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City | TUSCALOOSA
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State | AL
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Zip | 35401-2842
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Country | US
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Telephone | 205-391-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 3709 DIAMOND LN
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City | NORTHPORT
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State | AL
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Zip | 35473-2642
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Country | US
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Telephone | 205-792-4167
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 1-105627
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License Number State | AL
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