Provider Demographics
NPI:1003112871
Name:FANNIN, LISA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FANNIN
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 NANCY DR
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-3310
Mailing Address - Country:US
Mailing Address - Phone:209-765-5057
Mailing Address - Fax:
Practice Address - Street 1:728 NANCY DR
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-3310
Practice Address - Country:US
Practice Address - Phone:209-765-5057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP 13292235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist