Provider Demographics
NPI:1366842700
Name:FERNANDEZ, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:6405 NW 36TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6977
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6405 NW 36TH ST STE 105
Practice Address - Street 2:
Practice Address - City:VIRGINIA GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33166-6977
Practice Address - Country:US
Practice Address - Phone:305-526-2426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ6829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist