Provider Demographics
NPI:1790435543
Name:FANNIN, JAMIE (MS, ACSM-CEP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:FANNIN
Suffix:
Gender:F
Credentials:MS, ACSM-CEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E MAXWELL ST STE 103
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40508-2621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 E MAXWELL ST STE 103
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-2621
Practice Address - Country:US
Practice Address - Phone:859-323-5424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY429776Medicaid
KY1065850Medicaid