Provider Demographics
NPI:1053151985
Name:FANNING, ALEXIS SHANTE'
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:SHANTE'
Last Name:FANNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 LARAMIE ST UNIT AB
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2154
Mailing Address - Country:US
Mailing Address - Phone:307-638-8182
Mailing Address - Fax:
Practice Address - Street 1:4514 LARAMIE ST UNIT AB
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2154
Practice Address - Country:US
Practice Address - Phone:307-638-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker