Provider Demographics
NPI:1487140729
Name:MAGASSOUBA, FANTA
Entity type:Individual
Prefix:
First Name:FANTA
Middle Name:
Last Name:MAGASSOUBA
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 1:425 E 110TH ST APT 257
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3343
Mailing Address - Country:US
Mailing Address - Phone:347-280-9177
Mailing Address - Fax:
Practice Address - Street 1:329 E 149TH ST FL 4
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5626
Practice Address - Country:US
Practice Address - Phone:718-729-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY751978163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse