Provider Demographics
NPI:1174414437
Name:BROWN, FANTASIA R
Entity type:Individual
Prefix:
First Name:FANTASIA
Middle Name:R
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 O ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-1522
Mailing Address - Country:US
Mailing Address - Phone:402-805-2190
Mailing Address - Fax:402-805-2190
Practice Address - Street 1:2915 N 61ST ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68507-2404
Practice Address - Country:US
Practice Address - Phone:402-807-8911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider