Provider Demographics
NPI:1730135724
Name:FANGER, JULIE M (MSCCCA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:M
Last Name:FANGER
Suffix:
Gender:F
Credentials:MSCCCA
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:M
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 31001-698
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-0698
Mailing Address - Country:US
Mailing Address - Phone:602-263-1511
Mailing Address - Fax:
Practice Address - Street 1:4212 N 16TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5319
Practice Address - Country:US
Practice Address - Phone:602-263-1511
Practice Address - Fax:602-263-1619
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA0095231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
030078Medicare Oscar/Certification
P91247Medicare UPIN
8HBN19Medicare ID - Type UnspecifiedPART B