Healthcare Provider Details

I. General information

NPI: 1760991988
Provider Name (Legal Business Name): MARK ALEXANDER FONSECA ARNP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 SW 134TH CT
MIAMI FL
33184-1177
US

IV. Provider business mailing address

10310 SW 142ND CT
MIAMI FL
33186-8422
US

V. Phone/Fax

Practice location:
  • Phone: 786-493-6556
  • Fax:
Mailing address:
  • Phone: 786-493-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9309582
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP9309582
License Number StateFL

VIII. Authorized Official

Name: MR. MARK ALEXANDER FONSECA
Title or Position: CCO
Credential: MSN, ARNP, AGPCNP-BC
Phone: 786-493-6556