Provider Demographics
NPI:1386487593
Name:FANFAN, RUTH
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:FANFAN
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 1:3702 SILVER LACE LN APT 16
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-3928
Mailing Address - Country:US
Mailing Address - Phone:561-676-5237
Mailing Address - Fax:
Practice Address - Street 1:777 GLADES RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6424
Practice Address - Country:US
Practice Address - Phone:561-297-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-15
Last Update Date:2024-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11033749363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner