Provider Demographics
NPI:1770296436
Name:FANNING, CHANDLER LORI
Entity type:Individual
Prefix:
First Name:CHANDLER
Middle Name:LORI
Last Name:FANNING
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 1:3212 SE BIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-6669
Mailing Address - Country:US
Mailing Address - Phone:360-635-3550
Mailing Address - Fax:
Practice Address - Street 1:1827 NE 44TH AVE STE 390
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1461
Practice Address - Country:US
Practice Address - Phone:503-963-6494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician