Provider Demographics
NPI:1467115949
Name:FANTROY, DORA LEE (MA/PHLEBOTOMIST)
Entity Type:Individual
Prefix:MS
First Name:DORA
Middle Name:LEE
Last Name:FANTROY
Suffix:
Gender:F
Credentials:MA/PHLEBOTOMIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 E ROUND GROVE RD APT 1311
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8375
Mailing Address - Country:US
Mailing Address - Phone:251-545-8360
Mailing Address - Fax:
Practice Address - Street 1:195 E ROUND GROVE RD APT 1311
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8375
Practice Address - Country:US
Practice Address - Phone:251-545-8360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX157743291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory