Provider Demographics
NPI:1568564383
Name:FANNER, JOHNNIE LAURAETTA (NP)
Entity Type:Individual
Prefix:MS
First Name:JOHNNIE
Middle Name:LAURAETTA
Last Name:FANNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SINGING WIND DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1028
Mailing Address - Country:US
Mailing Address - Phone:210-617-5300
Mailing Address - Fax:210-949-3452
Practice Address - Street 1:7400 MERTON MINTER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4404
Practice Address - Country:US
Practice Address - Phone:210-617-5300
Practice Address - Fax:210-949-3452
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221594374T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel