Provider Demographics
NPI:1326387853
Name:FANNING, MICHELLE P
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:P
Last Name:FANNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 W. CHARLESTON BLVD
Mailing Address - Street 2:C23
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102
Mailing Address - Country:US
Mailing Address - Phone:702-564-6538
Mailing Address - Fax:
Practice Address - Street 1:2821 W. CHARLESTON BOULEVARD
Practice Address - Street 2:C23
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-437-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner