Provider Demographics
NPI:1366150260
Name:FANOUS, CONCEPCION (RN)
Entity type:Individual
Prefix:MRS
First Name:CONCEPCION
Middle Name:
Last Name:FANOUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:FANOUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:220 SADDLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0811
Mailing Address - Country:US
Mailing Address - Phone:903-539-1426
Mailing Address - Fax:
Practice Address - Street 1:220 SADDLE CREEK DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0811
Practice Address - Country:US
Practice Address - Phone:903-539-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX521535163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse