Provider Demographics
NPI:1366913303
Name:FANNON, CLARE M (PT MHS)
Entity type:Individual
Prefix:
First Name:CLARE
Middle Name:M
Last Name:FANNON
Suffix:
Gender:F
Credentials:PT MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PARKVIEW CT
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1186
Mailing Address - Country:US
Mailing Address - Phone:267-474-3105
Mailing Address - Fax:
Practice Address - Street 1:3 PARKVIEW CT
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1186
Practice Address - Country:US
Practice Address - Phone:267-474-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA003300002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherNONE