Provider Demographics
NPI:1316030125
Name:FANTONI, NICOLE (OD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FANTONI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HAMPTON WAY STE 1A
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-2554
Mailing Address - Country:US
Mailing Address - Phone:401-783-7009
Mailing Address - Fax:401-789-3909
Practice Address - Street 1:20 HAMPTON WAY
Practice Address - Street 2:BLDG#1A
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-2553
Practice Address - Country:US
Practice Address - Phone:401-783-7009
Practice Address - Fax:401-789-3909
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1316030125Medicaid
RI0070084011Medicare PIN
U81049Medicare UPIN
RIU400250931Medicare PIN