Provider Demographics
NPI:1801045695
Name:BERETAY, FANTA
Entity Type:Individual
Prefix:
First Name:FANTA
Middle Name:
Last Name:BERETAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5783 DAFFODIL CT
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-9456
Mailing Address - Country:US
Mailing Address - Phone:614-493-9884
Mailing Address - Fax:614-991-4895
Practice Address - Street 1:5783 DAFFODIL CT
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-9456
Practice Address - Country:US
Practice Address - Phone:614-991-4895
Practice Address - Fax:614-991-4895
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRNCNP020429363L00000X
OHAPRN.CNP.020429363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily