Healthcare Provider Details

I. General information

NPI: 1508330150
Provider Name (Legal Business Name): ANDRES MARCO FRAGA MSN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7345 COURAGE WAY
CHATTANOOGA TN
37421-1555
US

IV. Provider business mailing address

166 TIMBERLAND TRL
RINGGOLD GA
30736-4554
US

V. Phone/Fax

Practice location:
  • Phone: 423-602-9797
  • Fax:
Mailing address:
  • Phone: 954-909-3932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN0000025231
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: