Provider Demographics
NPI:1457573123
Name:FONSECA, GLADYS MARIA
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:MARIA
Last Name:FONSECA
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 1:7333 MIAMI LAKES DR
Mailing Address - Street 2:#669
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-6903
Mailing Address - Country:US
Mailing Address - Phone:305-986-3114
Mailing Address - Fax:954-364-4882
Practice Address - Street 1:6550 SW 28TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33023-3823
Practice Address - Country:US
Practice Address - Phone:305-986-3114
Practice Address - Fax:954-364-4882
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLNA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor