Provider Demographics
NPI:1619447729
Name:FERNANDEZ, CARMEN S
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:S
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 1:6401 AKRON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-2924
Mailing Address - Country:US
Mailing Address - Phone:877-425-6215
Mailing Address - Fax:215-395-6489
Practice Address - Street 1:6401 AKRON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-2924
Practice Address - Country:US
Practice Address - Phone:877-425-6215
Practice Address - Fax:215-395-6489
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-01
Last Update Date:2018-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA787144251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA83-1692446OtherCEO