Provider Demographics
NPI:1619738499
Name:DE LA PAZ FERNANDEZ, ANNIA
Entity Type:Individual
Prefix:
First Name:ANNIA
Middle Name:
Last Name:DE LA PAZ 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 1:3410 FOXCROFT RD APT 202
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-4155
Mailing Address - Country:US
Mailing Address - Phone:786-872-3139
Mailing Address - Fax:
Practice Address - Street 1:3410 FOXCROFT RD APT 202
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33025-4155
Practice Address - Country:US
Practice Address - Phone:786-872-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-19
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-317752106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty