Provider Demographics
NPI:1669060497
Name:DUARTE, FANNY
Entity type:Individual
Prefix:
First Name:FANNY
Middle Name:
Last Name:DUARTE
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 1:26 HILLIARD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1200
Mailing Address - Country:US
Mailing Address - Phone:201-270-8141
Mailing Address - Fax:
Practice Address - Street 1:26 HILLIARD AVE APT 3
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1200
Practice Address - Country:US
Practice Address - Phone:201-270-8141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00143500225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist