Provider Demographics
NPI:1356865489
Name:GANN, LINNEA ANITA
Entity Type:Individual
Prefix:
First Name:LINNEA
Middle Name:ANITA
Last Name:GANN
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:PO BOX 772294
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2294
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:
Practice Address - Street 1:168 N CLINTON ST FL 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1419
Practice Address - Country:US
Practice Address - Phone:847-502-4898
Practice Address - Fax:773-633-9593
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135.000984390200000X
GAPOD001466213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty