Provider Demographics
NPI:1154547479
Name:FANTASIA, KIMBERLEY R (FNP)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:R
Last Name:FANTASIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 KENNEDY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4526
Mailing Address - Country:US
Mailing Address - Phone:207-681-3000
Mailing Address - Fax:
Practice Address - Street 1:200 KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4526
Practice Address - Country:US
Practice Address - Phone:207-681-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER051730363LF0000X
MEAP081842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily