Provider Demographics
NPI:1215825054
Name:FANTER, AMY (LMT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:FANTER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2536 FARRAGUT DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-1540
Mailing Address - Country:US
Mailing Address - Phone:217-502-1181
Mailing Address - Fax:844-881-1788
Practice Address - Street 1:2536 FARRAGUT DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-1540
Practice Address - Country:US
Practice Address - Phone:217-502-1181
Practice Address - Fax:844-881-1788
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.011712225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist