Provider Demographics
NPI:1710597448
Name:FAHNESTOCK, BRIANNA (OD)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:FAHNESTOCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:
Other - Last Name:MISKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-464-1479
Mailing Address - Fax:
Practice Address - Street 1:36824 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-2770
Practice Address - Country:US
Practice Address - Phone:586-276-9300
Practice Address - Fax:586-261-5094
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005433152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist