Provider Demographics
NPI:1972646008
Name:FANT, JOSEPH ERNEST (LVN)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ERNEST
Last Name:FANT
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7484 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-4621
Mailing Address - Country:US
Mailing Address - Phone:858-688-3840
Mailing Address - Fax:760-317-2234
Practice Address - Street 1:7484 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-4621
Practice Address - Country:US
Practice Address - Phone:858-688-3840
Practice Address - Fax:760-317-2234
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA164209164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN000500Medicaid