1922014018 NPI number — MS. REBECCA K. FANNIN NP

Table of content: MS. REBECCA K. FANNIN NP (NPI 1922014018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922014018 NPI number — MS. REBECCA K. FANNIN NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FANNIN
Provider First Name:
REBECCA
Provider Middle Name:
K.
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLZ
Provider Other First Name:
REBECCA
Provider Other Middle Name:
K.
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922014018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9000 W WISCONSIN AVE
Provider Second Line Business Mailing Address:
PEDIATRIC ENDOCRINOLOGY
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-4874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-266-6750
Provider Business Mailing Address Fax Number:
414-266-6749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9000 W WISCONSIN AVE
Provider Second Line Business Practice Location Address:
PEDIATRIC ENDOCRINOLOGY
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-4874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-266-6750
Provider Business Practice Location Address Fax Number:
414-266-6749
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  121825 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41270500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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