Healthcare Provider Details

I. General information

NPI: 1639868094
Provider Name (Legal Business Name): LETICIA THAIS FAGUNDES FIDELIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LETICIA THAIS FIDELIS-RECINE

II. Dates (important events)

Enumeration Date: 05/02/2023
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10334B VISTA DR
CUPERTINO CA
95014-2039
US

IV. Provider business mailing address

10334B VISTA DR
CUPERTINO CA
95014-2039
US

V. Phone/Fax

Practice location:
  • Phone: 510-630-5988
  • Fax:
Mailing address:
  • Phone: 510-630-5988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: