Provider Demographics
NPI:1770584542
Name:FARGO, CHRISTINE MARIE (ARNP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:FARGO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561600
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1600
Mailing Address - Country:US
Mailing Address - Phone:321-868-8320
Mailing Address - Fax:321-632-3445
Practice Address - Street 1:2300 STATE ROAD 524
Practice Address - Street 2:SUITE 104
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32926-5894
Practice Address - Country:US
Practice Address - Phone:321-868-8320
Practice Address - Fax:321-632-3445
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3328432363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306115900Medicaid
FLU2216ZMedicare ID - Type Unspecified
FL306115900Medicaid