Provider Demographics
NPI:1598355398
Name:FENOLLAR, NAYET DE LA CARIDAD
Entity Type:Individual
Prefix:
First Name:NAYET
Middle Name:DE LA CARIDAD
Last Name:FENOLLAR
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 1:704 ORWELL AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-5901
Mailing Address - Country:US
Mailing Address - Phone:281-918-9827
Mailing Address - Fax:
Practice Address - Street 1:704 ORWELL AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-5901
Practice Address - Country:US
Practice Address - Phone:281-918-9827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-140756106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-20-140756Medicaid