Healthcare Provider Details

I. General information

NPI: 1154259620
Provider Name (Legal Business Name): DEBRA ANN FONSECA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 BAY SHORE RD
SARASOTA FL
34243-2101
US

IV. Provider business mailing address

3100 HARBOR BLVD APT 101
PORT CHARLOTTE FL
33952-6701
US

V. Phone/Fax

Practice location:
  • Phone: 518-496-6994
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4763
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: