Provider Demographics
NPI:1053675033
Name:FERNANDEZ, JOANNA R (APRN)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:R
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:982 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-1913
Mailing Address - Country:US
Mailing Address - Phone:203-696-3260
Mailing Address - Fax:203-332-0376
Practice Address - Street 1:500 PALISADE AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-3458
Practice Address - Country:US
Practice Address - Phone:203-579-6234
Practice Address - Fax:203-332-0376
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004898363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004898OtherSTATE LICENSE
CT004234788Medicaid
CTMF2603303OtherDEA