Provider Demographics
NPI:1811792294
Name:FUENTES, MIRTA (CASE MANAGER)
Entity type:Individual
Prefix:MS
First Name:MIRTA
Middle Name:
Last Name:FUENTES
Suffix:
Gender:
Credentials:CASE MANAGER
Other - Prefix:MRS
Other - First Name:MIRTA
Other - Middle Name:ROSA
Other - Last Name:BALLESTE NEGRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1237 W DIVIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1237 W DIVIDE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1220
Practice Address - Country:US
Practice Address - Phone:701-328-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator