Provider Demographics
NPI:1578687208
Name:FERNANDEZ-WALLACE, SERENA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:SERENA
Middle Name:MARIE
Last Name:FERNANDEZ-WALLACE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:SERENA
Other - Middle Name:MARIE
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:199 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4213
Mailing Address - Country:US
Mailing Address - Phone:631-425-0500
Mailing Address - Fax:631-425-3399
Practice Address - Street 1:199 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4213
Practice Address - Country:US
Practice Address - Phone:631-425-0500
Practice Address - Fax:631-425-3399
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009610-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor