Healthcare Provider Details

I. General information

NPI: 1154784940
Provider Name (Legal Business Name): FENICIA CANTY LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 SW MICHIGAN ST
LAKE CITY FL
32025-0440
US

IV. Provider business mailing address

PO BOX 412
LAKE CITY FL
32056-0412
US

V. Phone/Fax

Practice location:
  • Phone: 386-487-0800
  • Fax:
Mailing address:
  • Phone: 904-508-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5178257
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: