Provider Demographics
NPI:1194079400
Name:IN, VANNA (MA)
Entity type:Individual
Prefix:
First Name:VANNA
Middle Name:
Last Name:IN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4974 E BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-5016
Mailing Address - Country:US
Mailing Address - Phone:559-916-7642
Mailing Address - Fax:
Practice Address - Street 1:3467 W SHAW AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3223
Practice Address - Country:US
Practice Address - Phone:559-271-3096
Practice Address - Fax:559-274-0292
Is Sole Proprietor?:No
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator