Provider Demographics
NPI:1891353090
Name:FIDALGO, LISIANE
Entity Type:Individual
Prefix:
First Name:LISIANE
Middle Name:
Last Name:FIDALGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISIANE
Other - Middle Name:GONCALVES
Other - Last Name:FIDALGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4620 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-1843
Mailing Address - Country:US
Mailing Address - Phone:617-953-8077
Mailing Address - Fax:
Practice Address - Street 1:2500 VINSON AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232-4120
Practice Address - Country:US
Practice Address - Phone:617-953-8077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program