Provider Demographics
NPI:1023580461
Name:CLANCY, FALLON ANN (PA)
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:ANN
Last Name:CLANCY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 GEORGIANA ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-3911
Mailing Address - Country:US
Mailing Address - Phone:360-565-0999
Mailing Address - Fax:360-565-9251
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3997
Practice Address - Country:US
Practice Address - Phone:360-565-0999
Practice Address - Fax:360-565-9251
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
WAPA60922624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical