Provider Demographics
NPI:1649958042
Name:FAGUNDO, TANIA
Entity type:Individual
Prefix:
First Name:TANIA
Middle Name:
Last Name:FAGUNDO
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 1:19443 NW 87TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-6216
Mailing Address - Country:US
Mailing Address - Phone:786-449-8286
Mailing Address - Fax:
Practice Address - Street 1:15924 SW 92ND AVE
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1842
Practice Address - Country:US
Practice Address - Phone:786-449-8286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027339363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health