Provider Demographics
NPI:1134898265
Name:FANNIN, LINDSEY BRYANT
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:BRYANT
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 1:1050 BRITTANY WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4782
Mailing Address - Country:US
Mailing Address - Phone:205-243-7828
Mailing Address - Fax:
Practice Address - Street 1:1265 HIGHWAY 54 STE 500C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4537
Practice Address - Country:US
Practice Address - Phone:678-435-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-11
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN250418163WC0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN250418OtherREGISTERED NURSE LICENSE