Healthcare Provider Details

I. General information

NPI: 1336059914
Provider Name (Legal Business Name): TALITA GONCALVES DURAZZO C MASSAROTTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 45TH ST S
FARGO ND
58103-1189
US

IV. Provider business mailing address

5348 OLD JACKSONVILLE HWY APT 1322
TYLER TX
75703-3367
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone: 561-403-7418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: