Provider Demographics
NPI:1235381500
Name:FANNING, ELISSA MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:MARIE
Last Name:FANNING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 DENIM PL
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-1717
Mailing Address - Country:US
Mailing Address - Phone:914-309-6525
Mailing Address - Fax:
Practice Address - Street 1:24 DENIM PL
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-1717
Practice Address - Country:US
Practice Address - Phone:914-309-6525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-18
Last Update Date:2008-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPT018891-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist