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General NPI Number Information
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NPI Number | 1912581885
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Entity Type | Individual
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Provider Name | FANTASIA REMONVIL
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Gender | Female
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Dates
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Enumeration Date | 05/07/2021
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Last Update Date | 03/04/2023
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Provider Practice Location Address
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Address Line | 1330 GA-74
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City | FAYETTEVILLE
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State | GA
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Zip | 30215-1458
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Country | US
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Telephone | 770-631-2502
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Fax |
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Provider Business Mailing Address
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Address Line | 175 BLOSSOM WOOD DRIVE
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City | SENOIA
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State | GA
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Zip | 30276
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Country | US
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Telephone | 404-717-4445
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 11418
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License Number State | GA
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