Provider Demographics
NPI:1295877934
Name:FANNON, BRAE ACREE (RN)
Entity type:Individual
Prefix:
First Name:BRAE
Middle Name:ACREE
Last Name:FANNON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 BENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELLERSLIE
Mailing Address - State:GA
Mailing Address - Zip Code:31807-5502
Mailing Address - Country:US
Mailing Address - Phone:706-610-7397
Mailing Address - Fax:
Practice Address - Street 1:7950 MARTIN LOOP
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5647
Practice Address - Country:US
Practice Address - Phone:706-544-1477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN123234163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics