Provider Demographics
NPI:1174875082
Name:EDICK, FANTAZIA M (LPN)
Entity type:Individual
Prefix:
First Name:FANTAZIA
Middle Name:M
Last Name:EDICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 CLAY AVE
Mailing Address - Street 2:2
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14613-1030
Mailing Address - Country:US
Mailing Address - Phone:585-478-0048
Mailing Address - Fax:
Practice Address - Street 1:614 CLAY AVE
Practice Address - Street 2:2
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14613-1030
Practice Address - Country:US
Practice Address - Phone:585-478-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10-311923164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse