Basic Information
Provider Information | |||||||||
NPI: | 1285930339 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FANTOM | ||||||||
FirstName: | DEANA | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JACOBSEN | ||||||||
OtherFirstName: | DEANA | ||||||||
OtherMiddleName: | FANTOM | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 840862 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752840862 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3033777638 | ||||||||
FaxNumber: | 3037800787 | ||||||||
Practice Location | |||||||||
Address1: | 8000 E MAPLEWOOD AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | GREENWOOD VILLAGE | ||||||||
State: | CO | ||||||||
PostalCode: | 801114727 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3034383999 | ||||||||
FaxNumber: | 7204399500 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/08/2011 | ||||||||
LastUpdateDate: | 05/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APN.0100067-CRNA | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   | 367500000X | 127479 | CO | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | RN1014827 | 01 | DC | STATE LICENSE | OTHER | 127479 | 01 | CO | COLORADO LICENSE | OTHER |