Provider Demographics
NPI:1144397936
Name:FANNY, ISMAEL D (LPN)
Entity Type:Individual
Prefix:
First Name:ISMAEL
Middle Name:D
Last Name:FANNY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 BAY VW
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1402
Mailing Address - Country:US
Mailing Address - Phone:608-255-1914
Mailing Address - Fax:413-383-1691
Practice Address - Street 1:116 BAY VW
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1402
Practice Address - Country:US
Practice Address - Phone:608-255-1914
Practice Address - Fax:413-383-1691
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI33573-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse