Provider Demographics
NPI:1659888980
Name:FRAGOSO, MELANIE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:
Last Name:FRAGOSO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 E KIRBY ST APT 1031
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-4043
Mailing Address - Country:US
Mailing Address - Phone:248-345-9932
Mailing Address - Fax:
Practice Address - Street 1:36475 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2018-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704296999NSA17640367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered