Provider Demographics
NPI:1134473796
Name:FERNANDEZ, KENDRA ELISE
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:ELISE
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 1:624 W WILSON ST APT A2
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2498
Mailing Address - Country:US
Mailing Address - Phone:760-855-4286
Mailing Address - Fax:
Practice Address - Street 1:17870 PARK CIR
Practice Address - Street 2:#105
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614
Practice Address - Country:US
Practice Address - Phone:949-418-7167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7974235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist