Healthcare Provider Details

I. General information

NPI: 1477962181
Provider Name (Legal Business Name): KEILA MABEL FATNASSI MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 VONDERBURG DR # 301
BRANDON FL
33511-5954
US

IV. Provider business mailing address

700 S HARBOUR ISLAND BLVD UNIT # 313
TAMPA FL
33602-5712
US

V. Phone/Fax

Practice location:
  • Phone: 813-881-1000
  • Fax:
Mailing address:
  • Phone: 813-846-7904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: