MEDICARE: CORRI LEEANN FANCHER FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	1048917	TX

General Provider Information

NPI Number	:	1033886494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORRI LEEANN FANCHER FNP-BC

Provider Business Mailing Address
First Line	:	4023 SHENANDALE ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1639
Country	:	US
Telephone Number	:	210-740-8678
Fax Number	:

Provider Business Practice Location Address
First Line	:	4023 SHENANDALE ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78230-1639
Country	:	US
Telephone Number	:	210-740-8678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2021
Last Update Date	:	08/24/2021

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