MEDICARE: DENISE FANNIN

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	374U00000X	Home Health Aide		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316541071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE FANNIN

Provider Business Mailing Address
First Line	:	1173 COUNTY ROAD 1 LOT 59
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-8107
Country	:	US
Telephone Number	:	740-479-7030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1173 COUNTY ROAD 1 LOT 59
Second Line	:
City	:	SOUTH POINT
State	:	OH
Zip	:	45680-8107
Country	:	US
Telephone Number	:	740-479-7030
Fax Number	:

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

Provider Enumeration Date	:	11/24/2020
Last Update Date	:	11/24/2020

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Directions to “ DENISE FANNIN ” Practice Location

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