Provider Demographics
NPI:1043438435
Name:LAWRENCE FANNING, PAMELA RAE (PA-C)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:RAE
Last Name:LAWRENCE FANNING
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:FANNING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:24 STEVENS ST
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3852
Mailing Address - Country:US
Mailing Address - Phone:203-852-2671
Mailing Address - Fax:203-852-2057
Practice Address - Street 1:24 STEVENS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3852
Practice Address - Country:US
Practice Address - Phone:203-852-2671
Practice Address - Fax:203-852-2057
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000711363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant