Provider Demographics
NPI:1316769540
Name:FANTAUZZI, DESTINY (FNP-C)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:FANTAUZZI
Suffix:
Gender:
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1066 NATHAN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34715
Mailing Address - Country:US
Mailing Address - Phone:786-546-9434
Mailing Address - Fax:
Practice Address - Street 1:1066 NATHAN RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34715
Practice Address - Country:US
Practice Address - Phone:786-546-9434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11035911363LF0000X
FLAPRN11035911363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily