Provider Demographics
NPI:1073994570
Name:FANTASIA, JENNIFER E (CD, CLC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:FANTASIA
Suffix:
Gender:F
Credentials:CD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 W CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-1743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37 DOUGLAS CIR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:RI
Practice Address - Zip Code:02828-1927
Practice Address - Country:US
Practice Address - Phone:401-524-7562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174N00000XOther Service ProvidersLactation Consultant, Non-RN