Provider Demographics
NPI:1033658323
Name:FUENTES, DERRAINNYA (PHD)
Entity Type:Individual
Prefix:DR
First Name:DERRAINNYA
Middle Name:
Last Name:FUENTES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19935 E CHANDLER HEIGHTS ROAD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142
Mailing Address - Country:US
Mailing Address - Phone:602-670-2115
Mailing Address - Fax:
Practice Address - Street 1:19935 E CHANDLER HEIGHTS RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-9350
Practice Address - Country:US
Practice Address - Phone:602-670-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4439413405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional