Healthcare Provider Details

I. General information

NPI: 1093528176
Provider Name (Legal Business Name): ILEE FAGARASS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 NEBRASKA AVE STE 2-B
FORT PIERCE FL
34950-4866
US

IV. Provider business mailing address

1510 MERRIMENT WAY
FORT PIERCE FL
34947-7719
US

V. Phone/Fax

Practice location:
  • Phone: 772-302-3767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11037407
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: