Provider Demographics
NPI:1891351821
Name:FANTA, MESERET BEKELE (RN)
Entity Type:Individual
Prefix:
First Name:MESERET
Middle Name:BEKELE
Last Name:FANTA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 7TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-2717
Mailing Address - Country:US
Mailing Address - Phone:831-227-7996
Mailing Address - Fax:
Practice Address - Street 1:1280 7TH AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-2717
Practice Address - Country:US
Practice Address - Phone:831-227-7996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA507046163WC0400X, 163WP0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0200XNursing Service ProvidersRegistered NursePediatrics