Provider Demographics
NPI:1407445190
Name:FANNING, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
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 1:102 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:AVIS
Mailing Address - State:PA
Mailing Address - Zip Code:17721-9105
Mailing Address - Country:US
Mailing Address - Phone:570-651-5101
Mailing Address - Fax:
Practice Address - Street 1:1440 ALLEGHENY ST
Practice Address - Street 2:
Practice Address - City:JERSEY SHORE
Practice Address - State:PA
Practice Address - Zip Code:17740-1116
Practice Address - Country:US
Practice Address - Phone:570-398-7757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-16
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician