Provider Demographics
NPI:1962002048
Name:FANNIN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:FANNIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27993 CREOLA RD
Mailing Address - Street 2:
Mailing Address - City:CREOLA
Mailing Address - State:OH
Mailing Address - Zip Code:45622-8907
Mailing Address - Country:US
Mailing Address - Phone:740-418-0857
Mailing Address - Fax:
Practice Address - Street 1:27993 CREOLA RD
Practice Address - Street 2:
Practice Address - City:CREOLA
Practice Address - State:OH
Practice Address - Zip Code:45622-8907
Practice Address - Country:US
Practice Address - Phone:740-418-0857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant