Provider Demographics
NPI:1629060546
Name:FANTER, KATHERINE M (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:FANTER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 ONEOTA DR
Mailing Address - Street 2:
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-9356
Mailing Address - Country:US
Mailing Address - Phone:515-577-8139
Mailing Address - Fax:
Practice Address - Street 1:901 MONTGOMERY ST
Practice Address - Street 2:WINNESHIEK MEDICAL CENTER
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2325
Practice Address - Country:US
Practice Address - Phone:515-221-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-093740163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA50171OtherWELLMARK GROUP #
IA0439414Medicaid
IAI11974Medicare ID - Type Unspecified
IA0439414Medicaid