Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | DO 4027 | FL |
NPI | 1104099944 |
---|---|
Provider Name | Deborah J Fantin |
First Address | Arcadia, FL 34266-3950 |
Second Address | Arcadia, FL 34266-3950 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2008 |
Last Update Date | 11/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
650942504 | TAX ID (01) | FL |