Provider Demographics
NPI:1326455379
Name:FERNANDEZ, MARIEL
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:FERNANDEZ
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 1:11003 SAULTELL AVE
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4009
Mailing Address - Country:US
Mailing Address - Phone:917-923-4486
Mailing Address - Fax:
Practice Address - Street 1:9777 QUEENS BLVD
Practice Address - Street 2:PENTHOUSE
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3335
Practice Address - Country:US
Practice Address - Phone:718-830-9274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY96781071174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist