Provider Demographics
NPI:1285930339
Name:FANTOM, DEANA MARIE (CRNA)
Entity type:Individual
Prefix:
First Name:DEANA
Middle Name:MARIE
Last Name:FANTOM
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:DEANA
Other - Middle Name:FANTOM
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 840862
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0862
Mailing Address - Country:US
Mailing Address - Phone:303-377-7638
Mailing Address - Fax:303-780-0787
Practice Address - Street 1:8000 E MAPLEWOOD AVE STE 200
Practice Address - Street 2:
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-4727
Practice Address - Country:US
Practice Address - Phone:303-438-3999
Practice Address - Fax:720-439-9500
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO127479367500000X
COAPN.0100067-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO127479OtherCOLORADO LICENSE
DCRN1014827OtherSTATE LICENSE