Provider Demographics
NPI:1235580481
Name:VEGA ROMAN, FANMY
Entity Type:Individual
Prefix:
First Name:FANMY
Middle Name:
Last Name:VEGA ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11862 NW 30TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3324
Mailing Address - Country:US
Mailing Address - Phone:954-544-8170
Mailing Address - Fax:
Practice Address - Street 1:11862 NW 30TH CT
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065
Practice Address - Country:US
Practice Address - Phone:954-544-8170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-20-43957103K00000X
FLV265-40-87-625-0247200000X
FL17-32544106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician