Provider Demographics
NPI:1952748113
Name:STATEN, FAWN DEBORAH (MS, AT)
Entity Type:Individual
Prefix:MISS
First Name:FAWN
Middle Name:DEBORAH
Last Name:STATEN
Suffix:
Gender:F
Credentials:MS, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3108
Mailing Address - Country:US
Mailing Address - Phone:614-774-3980
Mailing Address - Fax:
Practice Address - Street 1:442 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-3108
Practice Address - Country:US
Practice Address - Phone:614-774-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT - 0018262255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer