Provider Demographics
NPI:1457809881
Name:FANNIN, KEITH RAY (RN)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:RAY
Last Name:FANNIN
Suffix:
Gender:M
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:ONE MEDICAL CENTER DRIVE
Mailing Address - Street 2:DARTMOUTH HITCHCOCK - GENERAL SURGERY
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756
Mailing Address - Country:US
Mailing Address - Phone:603-650-7903
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DRIVE
Practice Address - Street 2:DARTMOUTH HITCHCOCK - GENERAL SURGERY
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756
Practice Address - Country:US
Practice Address - Phone:603-650-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.372827163WC0200X
NH077205-23363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner