Provider Demographics
NPI:1295714012
Name:FANNIN, LORI A (DPM)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:FANNIN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-1923
Mailing Address - Country:US
Mailing Address - Phone:419-468-6222
Mailing Address - Fax:419-468-8259
Practice Address - Street 1:315 N MARKET ST
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-1923
Practice Address - Country:US
Practice Address - Phone:419-468-6222
Practice Address - Fax:419-468-8259
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002701213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0829198Medicaid
OHU19156Medicare UPIN
OH0829198Medicaid