Provider Demographics
NPI:1992133524
Name:FANTZ, KIRSTEN (LPT)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:FANTZ
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 N 1ST ST
Mailing Address - Street 2:162; 135
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-6800
Mailing Address - Country:US
Mailing Address - Phone:559-221-1107
Mailing Address - Fax:559-221-5004
Practice Address - Street 1:3636 N 1ST ST
Practice Address - Street 2:162; 135
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6800
Practice Address - Country:US
Practice Address - Phone:559-221-1107
Practice Address - Fax:559-221-5004
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37243167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician