Provider Demographics
NPI:1346980786
Name:FERNANDES, CLARISSA MARYANNE
Entity Type:Individual
Prefix:
First Name:CLARISSA
Middle Name:MARYANNE
Last Name:FERNANDES
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 1:2830 CARRIAGE MOUND CT
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3000 HOSPITAL BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4915
Practice Address - Country:US
Practice Address - Phone:770-751-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-01
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist