Provider Demographics
NPI:1417204694
Name:FANTROY, NUSTASIA S (BA)
Entity type:Individual
Prefix:
First Name:NUSTASIA
Middle Name:S
Last Name:FANTROY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6310 N MERIDIAN AVE
Mailing Address - Street 2:APT 203
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-1122
Mailing Address - Country:US
Mailing Address - Phone:405-209-8324
Mailing Address - Fax:
Practice Address - Street 1:6310 N MERIDIAN AVE
Practice Address - Street 2:APT 203
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-1122
Practice Address - Country:US
Practice Address - Phone:405-209-8324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional