Provider Demographics
NPI:1376312645
Name:FANTAYE, DEJYITNU A
Entity Type:Individual
Prefix:
First Name:DEJYITNU
Middle Name:A
Last Name:FANTAYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:937 WHITTMORE DR
Mailing Address - Street 2:
Mailing Address - City:NOLENSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37135-2915
Mailing Address - Country:US
Mailing Address - Phone:615-668-8578
Mailing Address - Fax:
Practice Address - Street 1:937 WHITTMORE DR
Practice Address - Street 2:
Practice Address - City:NOLENSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37135-2915
Practice Address - Country:US
Practice Address - Phone:615-668-8578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPN0000085984164W00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No164W00000XNursing Service ProvidersLicensed Practical Nurse