Provider Demographics
NPI:1144958240
Name:FONSECA, LIBIA ROSA (NP)
Entity type:Individual
Prefix:
First Name:LIBIA
Middle Name:ROSA
Last Name:FONSECA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14130 PERSHING CRES APT 1N
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1923
Mailing Address - Country:US
Mailing Address - Phone:786-380-0816
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3876
Practice Address - Country:US
Practice Address - Phone:786-380-0816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY811391-01364SA2100X
NYF432435-01363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute CareGroup - Multi-Specialty