Basic Information
| Provider Information | |||||||||
| NPI: | 1972963734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANN | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 BURNAGE WAY | ||||||||
| Address2: | APR. 307 | ||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297307847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565094154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1624 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034540365 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2016 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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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 | 225100000X | 7463 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.