Provider Demographics
NPI:1215376181
Name:FERMIN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:FERMIN
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 1:1024 ROSEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-2838
Mailing Address - Country:US
Mailing Address - Phone:805-302-7140
Mailing Address - Fax:
Practice Address - Street 1:1024 ROSEWOOD AVE
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2838
Practice Address - Country:US
Practice Address - Phone:805-302-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA026391171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor