Provider Demographics
NPI:1033670450
Name:FANNING, BETHAN CLARE (MD)
Entity Type:Individual
Prefix:
First Name:BETHAN
Middle Name:CLARE
Last Name:FANNING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 BELLE HAVEN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307-1201
Mailing Address - Country:US
Mailing Address - Phone:703-765-6093
Mailing Address - Fax:
Practice Address - Street 1:1451 BELLE HAVEN RD STE 110
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22307-1201
Practice Address - Country:US
Practice Address - Phone:703-765-6093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101275377208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics