Provider Demographics
NPI:1538912852
Name:FANTROY, ALISHA RENEE
Entity type:Individual
Prefix:
First Name:ALISHA
Middle Name:RENEE
Last Name:FANTROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2269 STURTEVANT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-1240
Mailing Address - Country:US
Mailing Address - Phone:313-728-9917
Mailing Address - Fax:
Practice Address - Street 1:5203 CHRYSLER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-4168
Practice Address - Country:US
Practice Address - Phone:313-576-7309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide