Healthcare Provider Details

I. General information

NPI: 1003728254
Provider Name (Legal Business Name): ZIPPORAH VIDZO FONDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10421 HAVERFORD PL
FORT WAYNE IN
46845-6504
US

IV. Provider business mailing address

10421 HAVERFORD PL
FORT WAYNE IN
46845-6504
US

V. Phone/Fax

Practice location:
  • Phone: 407-364-6535
  • Fax:
Mailing address:
  • Phone: 407-364-6535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28248248A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: