Provider Demographics
NPI:1508623059
Name:FERNANDEZ, TYLER DALTON I (LVN)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:DALTON
Last Name:FERNANDEZ
Suffix:I
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11761 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5025
Mailing Address - Country:US
Mailing Address - Phone:530-273-4431
Mailing Address - Fax:530-272-1512
Practice Address - Street 1:11761 RIDGE RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5025
Practice Address - Country:US
Practice Address - Phone:530-273-4431
Practice Address - Fax:530-272-1512
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA700729164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty