Healthcare Provider Details

I. General information

NPI: 1841102712
Provider Name (Legal Business Name): VIVIAN FUENTES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 W 19TH ST
SAN ANGELO TX
76903-3768
US

IV. Provider business mailing address

810 W 19TH ST
SAN ANGELO TX
76903-3768
US

V. Phone/Fax

Practice location:
  • Phone: 830-513-9254
  • Fax:
Mailing address:
  • Phone: 830-513-9254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number45582
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: