Provider Demographics
NPI:1558919621
Name:FANNING, KATHY D
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:D
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 1:742 HERITAGE POST LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1692
Mailing Address - Country:US
Mailing Address - Phone:770-313-2257
Mailing Address - Fax:
Practice Address - Street 1:742 HERITAGE POST LN
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1692
Practice Address - Country:US
Practice Address - Phone:770-313-2257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator