Provider Demographics
NPI:1164124657
Name:FANANI, NATALIA (PA)
Entity Type:Individual
Prefix:
First Name:NATALIA
Middle Name:
Last Name:FANANI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 PUTNAM PIKE
Mailing Address - Street 2:
Mailing Address - City:CHEPACHET
Mailing Address - State:RI
Mailing Address - Zip Code:02814-1403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 LATHROP AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2340
Practice Address - Country:US
Practice Address - Phone:860-204-0332
Practice Address - Fax:860-204-0115
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6387363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical