Provider Demographics
NPI:1164028403
Name:FERNANDES, MICAELA LARA (CNM)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:LARA
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 E MONTEREY WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2616
Mailing Address - Country:US
Mailing Address - Phone:480-565-2165
Mailing Address - Fax:
Practice Address - Street 1:2045 S VINEYARD STE 136
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6891
Practice Address - Country:US
Practice Address - Phone:480-565-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife