Provider Demographics
NPI:1801042536
Name:MAK, FANNY (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:FANNY
Middle Name:
Last Name:MAK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5156
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-0156
Mailing Address - Country:US
Mailing Address - Phone:601-209-0724
Mailing Address - Fax:
Practice Address - Street 1:1101 MARKET ST
Practice Address - Street 2:BR-3D
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37402-2881
Practice Address - Country:US
Practice Address - Phone:423-751-8562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily