Provider Demographics
NPI:1215413240
Name:FASANO, SERENA (WHNP, MPH, CLC)
Entity Type:Individual
Prefix:MRS
First Name:SERENA
Middle Name:
Last Name:FASANO
Suffix:
Gender:F
Credentials:WHNP, MPH, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 BRADLEE RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3110
Mailing Address - Country:US
Mailing Address - Phone:781-395-1110
Mailing Address - Fax:
Practice Address - Street 1:13 BRADLEE RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3110
Practice Address - Country:US
Practice Address - Phone:781-395-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2311932207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics