Provider Demographics
NPI:1255662144
Name:FERNANDEZ, LUCELIN (LMT)
Entity Type:Individual
Prefix:MS
First Name:LUCELIN
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 43RD ST
Mailing Address - Street 2:
Mailing Address - City:COPIAGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11726-1120
Mailing Address - Country:US
Mailing Address - Phone:631-398-5829
Mailing Address - Fax:
Practice Address - Street 1:390 43RD ST
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-1120
Practice Address - Country:US
Practice Address - Phone:631-398-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-17
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021723171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021723OtherNYS LICENSED MASSAGE THERAPIST