Provider Demographics
NPI:1417190091
Name:FERNANDEZ, JOANNE GAMBOA
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:GAMBOA
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:B2 BRIER HILL CT
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3348
Mailing Address - Country:US
Mailing Address - Phone:732-967-1000
Mailing Address - Fax:732-967-1500
Practice Address - Street 1:B2 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3348
Practice Address - Country:US
Practice Address - Phone:732-967-1000
Practice Address - Fax:732-967-1500
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00969000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist