Healthcare Provider Details

I. General information

NPI: 1649958042
Provider Name (Legal Business Name): TANIA FAGUNDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15924 SW 92ND AVE
PALMETTO BAY FL
33157-1842
US

IV. Provider business mailing address

19443 NW 87TH CT
HIALEAH FL
33018-6216
US

V. Phone/Fax

Practice location:
  • Phone: 786-449-8286
  • Fax:
Mailing address:
  • Phone: 786-449-8286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11027339
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: