Provider Demographics
NPI:1003909805
Name:FAGNANI, HEATHER M (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:M
Last Name:FAGNANI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:KENNY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:121 JOHN ROBERT THOMAS DR
Mailing Address - Street 2:
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-2654
Mailing Address - Country:US
Mailing Address - Phone:610-363-6203
Mailing Address - Fax:
Practice Address - Street 1:121 JOHN ROBERT THOMAS DR
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2654
Practice Address - Country:US
Practice Address - Phone:610-363-6203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOET008970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U01440Medicare UPIN