Provider Demographics
NPI:1982255030
Name:NANTZ, JOHNNY WADE II
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:WADE
Last Name:NANTZ
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 SILK STOCKING RD
Mailing Address - Street 2:
Mailing Address - City:WALLINS CREEK
Mailing Address - State:KY
Mailing Address - Zip Code:40873-8963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:809 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965
Practice Address - Country:US
Practice Address - Phone:606-248-3042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator