Provider Demographics
NPI:1184286122
Name:FONSECA, MANUEL (MSN, FNP-C)
Entity type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:
Last Name:FONSECA
Suffix:
Gender:M
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11737 ANHINGA DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-5807
Mailing Address - Country:US
Mailing Address - Phone:352-215-1501
Mailing Address - Fax:
Practice Address - Street 1:330 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5400
Practice Address - Country:US
Practice Address - Phone:617-667-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine