Basic Information
| Provider Information | |||||||||
| NPI: | 1093150526 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAN | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | MC 26-20 | ||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178221334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702142192 | ||||||||
| FaxNumber: | 5702147342 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N ACADEMY AVE | ||||||||
| Address2: | MC 26-20 | ||||||||
| City: | DANVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178221334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702142192 | ||||||||
| FaxNumber: | 5702147342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2013 | ||||||||
| LastUpdateDate: | 05/10/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | Y | Other Service Providers | Genetic Counselor, MS |
No ID Information.