Provider Demographics
NPI:1467690925
Name:FAWN, MANORA (LMT)
Entity Type:Individual
Prefix:
First Name:MANORA
Middle Name:
Last Name:FAWN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-1632
Mailing Address - Country:US
Mailing Address - Phone:541-267-4439
Mailing Address - Fax:
Practice Address - Street 1:632 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-1632
Practice Address - Country:US
Practice Address - Phone:541-267-4439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4636172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist