Provider Demographics
NPI:1528502234
Name:FANTA, DEANNE (DVM)
Entity type:Individual
Prefix:
First Name:DEANNE
Middle Name:
Last Name:FANTA
Suffix:
Gender:F
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6393 LEE HWY
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2569
Mailing Address - Country:US
Mailing Address - Phone:423-822-8304
Mailing Address - Fax:
Practice Address - Street 1:6393 LEE HWY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2569
Practice Address - Country:US
Practice Address - Phone:423-822-8304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5804284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5804OtherSTATE BOARD OF VET MED