Healthcare Provider Details

I. General information

NPI: 1083035786
Provider Name (Legal Business Name): VANESSA FAGUNDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2013
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SW 16TH TER
MIAMI FL
33145-1433
US

IV. Provider business mailing address

1890 SW 16 TERRACE
MIAMI FL
33145
US

V. Phone/Fax

Practice location:
  • Phone: 786-382-5071
  • Fax:
Mailing address:
  • Phone: 786-382-5071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSZ8120
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA16246
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: