Healthcare Provider Details

I. General information

NPI: 1184292716
Provider Name (Legal Business Name): HEIDI YVONNE FANTASIA RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HEIDI YVONNE BARBE RN, BSN

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 1ST ST STE A
SAN FRANCISCO CA
94105-2661
US

IV. Provider business mailing address

5516 BILBAO PL
SARASOTA FL
34238-4708
US

V. Phone/Fax

Practice location:
  • Phone: 313-505-0112
  • Fax:
Mailing address:
  • Phone: 313-505-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number822836
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: