1467891341 NPI number — FANTASIA MIDORI HARRIS FNP

Table of content: FANTASIA MIDORI HARRIS FNP (NPI 1467891341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467891341 NPI number — FANTASIA MIDORI HARRIS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
FANTASIA
Provider Middle Name:
MIDORI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELLIS
Provider Other First Name:
FANTASIA
Provider Other Middle Name:
MIDORI
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467891341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1380 RIVER BEND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75247-4914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-743-6159
Provider Business Mailing Address Fax Number:
214-689-6482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1380 RIVER BEND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75247-4914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-743-6159
Provider Business Practice Location Address Fax Number:
214-689-6482
Provider Enumeration Date:
06/24/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  705421 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)