Provider Demographics
NPI:1235966086
Name:KEITA, FANTA (ATC)
Entity type:Individual
Prefix:
First Name:FANTA
Middle Name:
Last Name:KEITA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1083 MEIXSELL VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:SAYLORSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18353-8024
Mailing Address - Country:US
Mailing Address - Phone:929-451-9380
Mailing Address - Fax:
Practice Address - Street 1:1083 MEIXSELL VALLEY RD
Practice Address - Street 2:
Practice Address - City:SAYLORSBURG
Practice Address - State:PA
Practice Address - Zip Code:18353-8024
Practice Address - Country:US
Practice Address - Phone:929-451-9380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer