MEDICARE: MISS LINDA 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	225200000X	Physical Therapy Assistant	PTA27416	FL

General Provider Information

NPI Number	:	1578094074
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LINDA FANNIN

Provider Business Mailing Address
First Line	:	565 SW DALTON CIR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-5817
Country	:	US
Telephone Number	:	772-708-4600
Fax Number	:

Provider Business Practice Location Address
First Line	:	565 SW DALTON CIR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-5817
Country	:	US
Telephone Number	:	772-708-4600
Fax Number	:

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

Provider Enumeration Date	:	03/26/2017
Last Update Date	:	03/26/2017

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Directions to “ MISS LINDA FANNIN ” Practice Location

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