Healthcare Provider Details

I. General information

NPI: 1972646008
Provider Name (Legal Business Name): JOSEPH ERNEST FANT LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7484 SKYLINE DR
SAN DIEGO CA
92114-4621
US

IV. Provider business mailing address

7484 SKYLINE DR
SAN DIEGO CA
92114-4621
US

V. Phone/Fax

Practice location:
  • Phone: 858-688-3840
  • Fax: 760-317-2234
Mailing address:
  • Phone: 858-688-3840
  • Fax: 760-317-2234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number164209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: