Provider Demographics
NPI:1609169085
Name:FANOUS, RACHEL MARIE (CNM)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:MARIE
Last Name:FANOUS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:MARIE
Other - Last Name:ZIMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-2973
Mailing Address - Country:US
Mailing Address - Phone:817-702-2450
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-6500
Practice Address - Fax:817-927-3872
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX718375367A00000X
TXAP120600367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287016403Medicaid
TX8105NSOtherBCBS
TX287016403Medicaid