Provider Demographics
NPI:1972908911
Name:DIALLO, FANTA
Entity Type:Individual
Prefix:
First Name:FANTA
Middle Name:
Last Name:DIALLO
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 1:1423 TELLER AVE
Mailing Address - Street 2:1K
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-1002
Mailing Address - Country:US
Mailing Address - Phone:347-781-3761
Mailing Address - Fax:
Practice Address - Street 1:1423 TELLER AVE
Practice Address - Street 2:1K
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-1002
Practice Address - Country:US
Practice Address - Phone:347-781-3761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308350-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse