Provider Demographics
NPI:1659955268
Name:FAGO, BRIANNA VANCE (APRN)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:VANCE
Last Name:FAGO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9539 59TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9680
Mailing Address - Country:US
Mailing Address - Phone:440-821-8754
Mailing Address - Fax:
Practice Address - Street 1:600 N CATTLEMEN RD STE 200
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-6422
Practice Address - Country:US
Practice Address - Phone:941-377-9993
Practice Address - Fax:941-343-0026
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013046363LG0600X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care