Provider Demographics
NPI:1053655902
Name:FANNON, MICHELLE AIDA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:AIDA
Last Name:FANNON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2723 T ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-7323
Mailing Address - Country:US
Mailing Address - Phone:916-612-8624
Mailing Address - Fax:916-674-1787
Practice Address - Street 1:2723 T ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-7323
Practice Address - Country:US
Practice Address - Phone:916-612-8624
Practice Address - Fax:916-674-1787
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist