Provider Demographics
NPI:1124447313
Name:FRAGOSO-NINO, ANNA OLIVIA (C-PNP)
Entity type:Individual
Prefix:MISS
First Name:ANNA OLIVIA
Middle Name:
Last Name:FRAGOSO-NINO
Suffix:
Gender:F
Credentials:C-PNP
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:O
Other - Last Name:FRAGOSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14446 TAWNEY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-3210
Mailing Address - Country:US
Mailing Address - Phone:760-221-4726
Mailing Address - Fax:
Practice Address - Street 1:14446 TAWNEY RIDGE LN
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-3210
Practice Address - Country:US
Practice Address - Phone:760-221-4726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21714363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics