Provider Demographics
NPI:1346873684
Name:DAMUS, FANNY JACINDA
Entity Type:Individual
Prefix:
First Name:FANNY
Middle Name:JACINDA
Last Name:DAMUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FANNY
Other - Middle Name:JACINDA
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:931 2ND ST E APT 205
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-5402
Mailing Address - Country:US
Mailing Address - Phone:813-368-0225
Mailing Address - Fax:
Practice Address - Street 1:11623 ARBOR ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2981
Practice Address - Country:US
Practice Address - Phone:402-334-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND421855224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant