Provider Demographics
NPI:1568457513
Name:MANNING, FAWN TIENNE (DO)
Entity Type:Individual
Prefix:
First Name:FAWN
Middle Name:TIENNE
Last Name:MANNING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 E BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-2002
Mailing Address - Country:US
Mailing Address - Phone:410-558-3951
Mailing Address - Fax:
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:SUITE 380
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
Practice Address - Country:US
Practice Address - Phone:410-415-5577
Practice Address - Fax:410-415-6682
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0059003174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD400260100Medicaid
MDKM21E764Medicare ID - Type Unspecified
MD400260100Medicaid