Provider Demographics
NPI:1558944058
Name:FRAUSTO, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:FRAUSTO
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 1:638 S 33RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-2604
Mailing Address - Country:US
Mailing Address - Phone:619-919-5465
Mailing Address - Fax:
Practice Address - Street 1:5506 CANDLELIGHT DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-7711
Practice Address - Country:US
Practice Address - Phone:858-442-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-03
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB7949269OtherDRIVER LICENSE