Provider Demographics
NPI:1194547828
Name:PARKER, FANTASIA ELIZABETH
Entity type:Individual
Prefix:
First Name:FANTASIA
Middle Name:ELIZABETH
Last Name:PARKER
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 1:650 LYDIA NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-780-9845
Mailing Address - Fax:
Practice Address - Street 1:1115 BALL AVE NE,
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS,
Practice Address - State:MI
Practice Address - Zip Code:49505
Practice Address - Country:US
Practice Address - Phone:616-456-6571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker