Healthcare Provider Details

I. General information

NPI: 1154011641
Provider Name (Legal Business Name): FABIOLA ROCHO MARGARA MATY1
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/13/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 RACETRACK RD NW UNIT C
FORT WALTON BEACH FL
32547-1544
US

IV. Provider business mailing address

451 SHREWSBURY RD
MARY ESTHER FL
32569-1735
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-9012
  • Fax:
Mailing address:
  • Phone: 850-226-9012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number49710993
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number49710993
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: