Provider Demographics
NPI:1174675045
Name:FAN, FELICE SUI (MS, RD)
Entity type:Individual
Prefix:
First Name:FELICE
Middle Name:SUI
Last Name:FAN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:SUIHWA
Other - Middle Name:
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD
Mailing Address - Street 1:2 DEERPARK LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2965
Mailing Address - Country:US
Mailing Address - Phone:423-282-8590
Mailing Address - Fax:
Practice Address - Street 1:415 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6034
Practice Address - Country:US
Practice Address - Phone:423-975-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
716340133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered