Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 020014613 | IL |
NPI | 1003233909 |
---|---|
Provider Name | Faith Fann |
First Address | Christopher, IL 62822-0155 |
Second Address | Christopher, IL 62822 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2014 |
Last Update Date | 28/03/2014 |