Provider Demographics
NPI:1609401967
Name:FANTAUZZI, LUCILLE MALVINA (APRN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LUCILLE
Middle Name:MALVINA
Last Name:FANTAUZZI
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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Mailing Address - Street 1:1265 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-6574
Mailing Address - Country:US
Mailing Address - Phone:772-567-6340
Mailing Address - Fax:772-567-3564
Practice Address - Street 1:1265 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6574
Practice Address - Country:US
Practice Address - Phone:772-567-6340
Practice Address - Fax:772-567-3564
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9342743163W00000X
FLAPRN11006482363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse