MEDICARE: MS. AUDREY LEE FAN MS

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	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1093150526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUDREY LEE FAN MS

Provider Business Mailing Address
First Line	:	100 N ACADEMY AVE
Second Line	:	MC 26-20
City	:	DANVILLE
State	:	PA
Zip	:	17822-1334
Country	:	US
Telephone Number	:	570-214-2192
Fax Number	:	570-214-7342

Provider Business Practice Location Address
First Line	:	100 N ACADEMY AVE
Second Line	:	MC 26-20
City	:	DANVILLE
State	:	PA
Zip	:	17822-1334
Country	:	US
Telephone Number	:	570-214-2192
Fax Number	:	570-214-7342

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

Provider Enumeration Date	:	05/10/2013
Last Update Date	:	05/10/2013

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