Provider Demographics
NPI:1194219097
Name:FANNING, MARY THERESA (CRNP)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:THERESA
Last Name:FANNING
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:17327-1341
Mailing Address - Country:US
Mailing Address - Phone:717-701-6046
Mailing Address - Fax:
Practice Address - Street 1:2350 FREEDOM WAY STE 200
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-8200
Practice Address - Country:US
Practice Address - Phone:717-812-5120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018724363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily