Provider Demographics
NPI:1477645026
Name:FANN, ALICE VIRGINIA (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:VIRGINIA
Last Name:FANN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 FORT ROOTS DR
Mailing Address - Street 2:RT 117/NLR, DEPT. OF PM&R
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-1709
Mailing Address - Country:US
Mailing Address - Phone:501-257-2995
Mailing Address - Fax:501-257-2993
Practice Address - Street 1:2200 FORT ROOTS DR
Practice Address - Street 2:RT 117/NLR
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-1709
Practice Address - Country:US
Practice Address - Phone:501-257-2995
Practice Address - Fax:501-257-2993
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-0357208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation