Basic Information
| Provider Information | |||||||||
| NPI: | 1265917918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANNING | ||||||||
| FirstName: | CORTNEY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 150 RIVER NORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | STEPHENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764011860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2549686051 | ||||||||
| FaxNumber: | 2549684950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2018 | ||||||||
| LastUpdateDate: | 09/20/2019 | ||||||||
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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 | 363LF0000X | AP138958 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 391130701 | 05 | TX | MEDICAID |