Provider Demographics
NPI:1154181006
Name:FRAGOSO, MARISA
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:FRAGOSO
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 1:53 TORINO CT
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-1930
Mailing Address - Country:US
Mailing Address - Phone:925-786-0418
Mailing Address - Fax:
Practice Address - Street 1:1357 OAKLAND CT
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-4337
Practice Address - Country:US
Practice Address - Phone:925-935-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95331760163WC0400X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase Management