Provider Demographics
NPI:1093150526
Name:FAN, AUDREY LEE (MS)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:LEE
Last Name:FAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:MC 26-20
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-1334
Mailing Address - Country:US
Mailing Address - Phone:570-214-2192
Mailing Address - Fax:570-214-7342
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:MC 26-20
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-1334
Practice Address - Country:US
Practice Address - Phone:570-214-2192
Practice Address - Fax:570-214-7342
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS