Provider Demographics
NPI:1861002701
Name:FANTOZZI, KATHLEEN P (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:P
Last Name:FANTOZZI
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 UNION ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-1768
Mailing Address - Country:US
Mailing Address - Phone:603-860-8905
Mailing Address - Fax:
Practice Address - Street 1:1590 UNION ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-1768
Practice Address - Country:US
Practice Address - Phone:603-860-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2020015527207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine