Provider Demographics
NPI:1962823518
Name:FANUS, JODI L (CRNA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:FANUS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:
Other - Last Name:MICHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:800-243-1455
Practice Address - Fax:717-531-7790
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN526788L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1036957470001Medicaid