Provider Demographics
NPI:1083035786
Name:FAGUNDO, VANESSA
Entity type:Individual
Prefix:
First Name:VANESSA
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 1:1890 SW 16 TERRACE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145
Mailing Address - Country:US
Mailing Address - Phone:786-382-5071
Mailing Address - Fax:
Practice Address - Street 1:1890 SW 16TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-1433
Practice Address - Country:US
Practice Address - Phone:786-382-5071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-23
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8120235Z00000X
FLSA16246235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist