Provider Demographics
NPI:1902542616
Name:MACEDO, FANTASIA MARIE
Entity Type:Individual
Prefix:
First Name:FANTASIA
Middle Name:MARIE
Last Name:MACEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FANTASIA
Other - Middle Name:SAMANTHA MARIE
Other - Last Name:GARCIA HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1911 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-4443
Mailing Address - Country:US
Mailing Address - Phone:509-386-2571
Mailing Address - Fax:
Practice Address - Street 1:401 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2846
Practice Address - Country:US
Practice Address - Phone:509-897-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61172658163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse