Provider Demographics
NPI:1043085665
Name:FERNANDEZ, VIVIAN KEILY
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:KEILY
Last Name:FERNANDEZ
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 1:4322 NW 203RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-1545
Mailing Address - Country:US
Mailing Address - Phone:786-560-1188
Mailing Address - Fax:
Practice Address - Street 1:4322 NW 203RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-1545
Practice Address - Country:US
Practice Address - Phone:786-560-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-24
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23311758106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician