Provider Demographics
NPI:1942566708
Name:THOMAS-FANNIN, ALLIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLIE
Middle Name:E
Last Name:THOMAS-FANNIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1034
Mailing Address - Country:US
Mailing Address - Phone:812-886-6800
Mailing Address - Fax:
Practice Address - Street 1:121 BUNTIN ST
Practice Address - Street 2:SUITE #1
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1320
Practice Address - Country:US
Practice Address - Phone:812-885-2718
Practice Address - Fax:812-885-2727
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01076813A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201364350Medicaid
IN201364350Medicaid