Provider Demographics
NPI:1982806519
Name:FANN, JUDSON (MS, ATC, LAT, CSCS)
Entity type:Individual
Prefix:MR
First Name:JUDSON
Middle Name:
Last Name:FANN
Suffix:
Gender:M
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 E VILLA CAPRI CIR
Mailing Address - Street 2:APT. A
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-7866
Mailing Address - Country:US
Mailing Address - Phone:386-848-6715
Mailing Address - Fax:
Practice Address - Street 1:421 N WOODLAND BLVD
Practice Address - Street 2:UNIT 8317
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32723-0001
Practice Address - Country:US
Practice Address - Phone:386-822-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL19822255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer