Provider Demographics
NPI:1316035603
Name:FAVA, JOANNE J (DC)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:J
Last Name:FAVA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1188 JACARANDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-4501
Mailing Address - Country:US
Mailing Address - Phone:941-492-6880
Mailing Address - Fax:941-492-6881
Practice Address - Street 1:1188 JACARANDA BLVD
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-4501
Practice Address - Country:US
Practice Address - Phone:941-492-6880
Practice Address - Fax:941-492-6881
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6997111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55311AMedicare PIN