Healthcare Provider Details

I. General information

NPI: 1922873777
Provider Name (Legal Business Name): ALEXIS FAGUNDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S BUENA VISTA ST
BURBANK CA
91505-4809
US

IV. Provider business mailing address

3936 PARK PL
MONTROSE CA
91020-1609
US

V. Phone/Fax

Practice location:
  • Phone: 626-566-8501
  • Fax:
Mailing address:
  • Phone: 818-261-7059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95027346
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: