Provider Demographics
NPI:1174992739
Name:FASOLO, LEAH MARIE (APRN, ARNP)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIE
Last Name:FASOLO
Suffix:
Gender:F
Credentials:APRN, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-0550
Mailing Address - Fax:239-343-4013
Practice Address - Street 1:13340 METRO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4818
Practice Address - Country:US
Practice Address - Phone:239-343-0550
Practice Address - Fax:239-343-4013
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9477790363L00000X
FLAPRN9477790363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101880700Medicaid