Provider Demographics
NPI:1700277894
Name:FANNIN, KERRY (CSW)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:FANNIN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1739 SOUTH 2900 EAST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660
Mailing Address - Country:US
Mailing Address - Phone:661-317-6067
Mailing Address - Fax:
Practice Address - Street 1:4734 W 12400 S
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-9637
Practice Address - Country:US
Practice Address - Phone:661-317-6067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7125639-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical