Provider Demographics
NPI:1306044607
Name:FANTAUZZO, CATHERINE (LPN)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:
Last Name:FANTAUZZO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1342 EMERSON ST
Mailing Address - Street 2:UNIT D
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14606-3054
Mailing Address - Country:US
Mailing Address - Phone:585-314-3433
Mailing Address - Fax:
Practice Address - Street 1:1342 EMERSON ST
Practice Address - Street 2:UNIT D
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-3054
Practice Address - Country:US
Practice Address - Phone:585-314-3438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-07
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236691-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02395917Medicaid