Provider Demographics
NPI:1467891341
Name:HARRIS, FANTASIA MIDORI (FNP)
Entity Type:Individual
Prefix:
First Name:FANTASIA
Middle Name:MIDORI
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:FANTASIA
Other - Middle Name:MIDORI
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1380 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4914
Mailing Address - Country:US
Mailing Address - Phone:214-743-6159
Mailing Address - Fax:214-689-6482
Practice Address - Street 1:1380 RIVER BEND DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4914
Practice Address - Country:US
Practice Address - Phone:214-743-6159
Practice Address - Fax:214-689-6482
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX705421363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily