Provider Demographics
NPI:1972052819
Name:FANCETT, LINDSEY (PA-C)
Entity type:Individual
Prefix:MS
First Name:LINDSEY
Middle Name:
Last Name:FANCETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3075 GOVERNORS PLACE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1323
Practice Address - Country:US
Practice Address - Phone:193-742-4258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004657RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1316923915OtherORGANIZATION