Provider Demographics
NPI:1699568444
Name:FANNING, MATTHEW CLARK (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CLARK
Last Name:FANNING
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 DIAMOND LN
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-2642
Mailing Address - Country:US
Mailing Address - Phone:205-792-4167
Mailing Address - Fax:
Practice Address - Street 1:1401 GREENSBORO AVE
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-2842
Practice Address - Country:US
Practice Address - Phone:205-391-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-105627363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health