Provider Demographics
NPI:1174803233
Name:MUNRO, FAWN LEA (NP)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:LEA
Last Name:MUNRO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 LONG RAPIDS PLZ
Mailing Address - Street 2:
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-1442
Mailing Address - Country:US
Mailing Address - Phone:989-356-0141
Mailing Address - Fax:989-354-5670
Practice Address - Street 1:460 LONG RAPIDS PLZ
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707
Practice Address - Country:US
Practice Address - Phone:989-356-0141
Practice Address - Fax:989-354-5670
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260153363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner