Provider Demographics
NPI:1194846394
Name:FERNANDO, NILUSHA TANIA (DO)
Entity Type:Individual
Prefix:
First Name:NILUSHA
Middle Name:TANIA
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 WAYMONT CT STE 111
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3572
Mailing Address - Country:US
Mailing Address - Phone:407-936-3345
Mailing Address - Fax:
Practice Address - Street 1:325 WAYMONT CT STE 111
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3572
Practice Address - Country:US
Practice Address - Phone:407-936-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10654208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCK177TMedicare UPIN