Provider Demographics
NPI:1326446709
Name:FERNANDEZ, MARISOL (SFIDC)
Entity Type:Individual
Prefix:
First Name:MARISOL
Middle Name:
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 DENVER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-6319
Mailing Address - Country:US
Mailing Address - Phone:310-740-5109
Mailing Address - Fax:
Practice Address - Street 1:5929 DENVER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-6319
Practice Address - Country:US
Practice Address - Phone:310-740-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman