Provider Demographics
NPI:1275415580
Name:FANNIN, ADAM THOMAS (MSN, MHA, APRN-CNP)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:THOMAS
Last Name:FANNIN
Suffix:
Gender:M
Credentials:MSN, MHA, APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3417 VIRGINIA AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1308
Mailing Address - Country:US
Mailing Address - Phone:740-395-6011
Mailing Address - Fax:
Practice Address - Street 1:3100 MACCORKLE AVE SE STE 205
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1228
Practice Address - Country:US
Practice Address - Phone:740-395-6011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-25
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV108310163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine