Provider Demographics
NPI:1972963734
Name:FANN, ASHLEY M (DPT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:M
Last Name:FANN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 BURNAGE WAY
Mailing Address - Street 2:APR. 307
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-7847
Mailing Address - Country:US
Mailing Address - Phone:256-509-4154
Mailing Address - Fax:
Practice Address - Street 1:1624 MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2818
Practice Address - Country:US
Practice Address - Phone:803-454-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist