Healthcare Provider Details

I. General information

NPI: 1073721304
Provider Name (Legal Business Name): LISA SONIA FRUTOS RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 12/30/2022
Certification Date: 12/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 O ST
FIREBAUGH CA
93622-2224
US

IV. Provider business mailing address

1574 ESCALON AVE
CLOVIS CA
93611-0501
US

V. Phone/Fax

Practice location:
  • Phone: 559-659-9000
  • Fax:
Mailing address:
  • Phone: 559-824-1828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12078
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: