Individual
DAJUAN FANNING
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
17072 NEW HAMPSHIRE DR, SOUTHFIELD, MI 48075-2972
(313) 213-7470
Mailing address
17072 NEW HAMPSHIRE DR, SOUTHFIELD, MI 48075-2972
(313) 213-7470
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
4703116420
MI
372500000X
Chore Provider
—
—
374U00000X
Home Health Aide
—
—
405300000X
Prevention Professional
4703116420
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4703116420
BCBS
MI
05
—
4703116420
—
MI
Enumeration date
06/11/2019
Last updated
06/11/2019
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