Provider Demographics
NPI:1518404391
Name:FANTA, TYLER (RN)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:FANTA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 WEALD BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 WEALD BRIDGE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9363
Practice Address - Country:US
Practice Address - Phone:608-317-2830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI171092-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse