Provider Demographics
NPI:1740770338
Name:FANNIN, STEPHANIE DIANE (RN, BSN, CCM)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:DIANE
Last Name:FANNIN
Suffix:
Gender:F
Credentials:RN, BSN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3191 MEDICAL CENTER DR APT 14106
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75069-1679
Mailing Address - Country:US
Mailing Address - Phone:214-799-9684
Mailing Address - Fax:
Practice Address - Street 1:3191 MEDICAL CENTER DR APT 14106
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75069-1679
Practice Address - Country:US
Practice Address - Phone:214-799-9684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX669441171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator