Provider Demographics
NPI:1659877124
Name:FERNANDEZ DE BULNES, INGRID MUINA
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:MUINA
Last Name:FERNANDEZ DE BULNES
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 1:16443 SW 97TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5850
Mailing Address - Country:US
Mailing Address - Phone:862-218-8271
Mailing Address - Fax:
Practice Address - Street 1:16443 SW 97TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-5850
Practice Address - Country:US
Practice Address - Phone:862-218-8271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022331900Medicaid