=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104669357
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAQUEL CAROLINE FERREIRA LOPES FONTANELLI PHD, BC-HIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2024
-----------------------------------------------------
Last Update Date | 06/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 1ST ST S
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33880-3601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-293-6507
-----------------------------------------------------
Fax | 863-291-0737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10375 VISTA OAKS CT UNIT 409
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32836-4672
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-253-4807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332S00000X
-----------------------------------------------------
Taxonomy Name | Hearing Aid Equipment
-----------------------------------------------------
License Number | AS5808
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | AS5808
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------