Basic Information
| Provider Information | |||||||||
| NPI: | 1568564383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANNER | ||||||||
| FirstName: | JOHNNIE | ||||||||
| MiddleName: | LAURAETTA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 SINGING WIND DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782271028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | 2109493452 | ||||||||
| Practice Location | |||||||||
| Address1: | 7400 MERTON MINTER ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106175300 | ||||||||
| FaxNumber: | 2109493452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 374T00000X | 221594 | TX | Y | Nursing Service Related Providers | Religious Nonmedical Nursing Personnel |
No ID Information.