Provider Demographics
NPI:1457882193
Name:FORBES, FANTIYA S
Entity Type:Individual
Prefix:
First Name:FANTIYA
Middle Name:S
Last Name:FORBES
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 1:724 E 27TH ST
Mailing Address - Street 2:6K
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2257
Mailing Address - Country:US
Mailing Address - Phone:347-593-0689
Mailing Address - Fax:
Practice Address - Street 1:724 E 27TH ST
Practice Address - Street 2:6K
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-2257
Practice Address - Country:US
Practice Address - Phone:347-593-0689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232066299174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist