Provider Demographics
NPI:1477220150
Name:FUENTES FONTE, LETICIA
Entity type:Individual
Prefix:
First Name:LETICIA
Middle Name:
Last Name:FUENTES FONTE
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 1:25505 SW 124TH CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-5865
Mailing Address - Country:US
Mailing Address - Phone:786-222-2962
Mailing Address - Fax:
Practice Address - Street 1:25505 SW 124TH CT
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-5865
Practice Address - Country:US
Practice Address - Phone:786-222-2962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008448363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily