Provider Demographics
NPI:1295018612
Name:FANNING, JOAN MARIE (RPH)
Entity type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:MARIE
Last Name:FANNING
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 SNAPJACK CIR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5398
Mailing Address - Country:US
Mailing Address - Phone:630-904-4765
Mailing Address - Fax:
Practice Address - Street 1:2719 HASSERT BLVD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5203
Practice Address - Country:US
Practice Address - Phone:630-922-6360
Practice Address - Fax:630-922-6365
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11882-40183500000X
IL039.051712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist