Provider Demographics
NPI:1225513799
Name:FASANO, LITA MARIA (EDM)
Entity Type:Individual
Prefix:
First Name:LITA
Middle Name:MARIA
Last Name:FASANO
Suffix:
Gender:F
Credentials:EDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ARMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-2406
Mailing Address - Country:US
Mailing Address - Phone:617-635-8534
Mailing Address - Fax:
Practice Address - Street 1:40 ARMINGTON ST
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-2406
Practice Address - Country:US
Practice Address - Phone:617-635-8534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA264106174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist