Provider Demographics
NPI:1346797115
Name:FERNANDINI, JOAN MARIE
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:FERNANDINI
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:BARRIO GRILLASCA
Mailing Address - Street 2:CARR 374 KM 02
Mailing Address - City:LARES
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00631
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CARRETERA 374 KM 02
Practice Address - Street 2:BARRIO GRILLASCA
Practice Address - City:LARES
Practice Address - State:PR
Practice Address - Zip Code:00631
Practice Address - Country:US
Practice Address - Phone:787-214-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1962133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered