Provider Demographics
NPI:1922014018
Name:FANNIN, REBECCA K (NP)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:K
Last Name:FANNIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:REBECCA
Other - Middle Name:K
Other - Last Name:HOLZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC ENDOCRINOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-6750
Mailing Address - Fax:414-266-6749
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC ENDOCRINOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-6750
Practice Address - Fax:414-266-6749
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI121825363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41270500Medicaid
WI1057 73-601Medicare PIN