Provider Demographics
NPI:1891053831
Name:FREGOSO, ANTOINETTE (APN)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:FREGOSO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W WINDHORST RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-2455
Mailing Address - Country:US
Mailing Address - Phone:813-373-9531
Mailing Address - Fax:
Practice Address - Street 1:3919 TAMPA RD
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3114
Practice Address - Country:US
Practice Address - Phone:727-733-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRN72796163W00000X
FLAPRN11004349363LF0000X, 363L00000X
FL1100439363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily