Provider Demographics
NPI:1376102434
Name:FANNING, DAJUAN
Entity Type:Individual
Prefix:
First Name:DAJUAN
Middle Name:
Last Name:FANNING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17072 NEW HAMPSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2972
Mailing Address - Country:US
Mailing Address - Phone:313-213-7470
Mailing Address - Fax:
Practice Address - Street 1:17072 NEW HAMPSHIRE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2972
Practice Address - Country:US
Practice Address - Phone:313-213-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X, 374U00000X
MI4703116420405300000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No372500000XNursing Service Related ProvidersChore Provider
No374U00000XNursing Service Related ProvidersHome Health Aide
No405300000XOther Service ProvidersPrevention Professional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4703116420Medicaid
MI4703116420OtherBCBS