Provider Demographics
NPI:1477097343
Name:FANTON, LISA (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FANTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 VIKING WAY APT C3
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-2433
Mailing Address - Country:US
Mailing Address - Phone:585-471-4676
Mailing Address - Fax:
Practice Address - Street 1:219 VIKING WAY APT C3
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-2433
Practice Address - Country:US
Practice Address - Phone:585-471-4676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251344-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse