Provider Demographics
NPI:1467907618
Name:FERNANDEZ, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:530 E RILEY DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-2154
Mailing Address - Country:US
Mailing Address - Phone:623-932-7300
Mailing Address - Fax:623-932-7311
Practice Address - Street 1:530 E RILEY DR
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-2154
Practice Address - Country:US
Practice Address - Phone:623-932-7300
Practice Address - Fax:623-932-7311
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86-6004326390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ594722OtherAHCCCS