Provider Demographics
NPI:1891228086
Name:FAGUNDES, NIVIA
Entity Type:Individual
Prefix:
First Name:NIVIA
Middle Name:
Last Name:FAGUNDES
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 1:112 CAPTAIN LOTHROP RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-2818
Mailing Address - Country:US
Mailing Address - Phone:774-208-1177
Mailing Address - Fax:
Practice Address - Street 1:677 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3493
Practice Address - Country:US
Practice Address - Phone:508-790-0606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA571155225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist