Provider Demographics
NPI:1750653929
Name:FERNANDEZ, DIVINA JAVIER (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:DIVINA
Middle Name:JAVIER
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E. MARCH LANE
Mailing Address - Street 2:STE C 320
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6676
Mailing Address - Country:US
Mailing Address - Phone:209-957-5888
Mailing Address - Fax:209-477-9339
Practice Address - Street 1:1801 E. MARCH LANE
Practice Address - Street 2:STE C320
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6676
Practice Address - Country:US
Practice Address - Phone:209-957-5888
Practice Address - Fax:209-477-9339
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN657995163W00000X
CANP19792363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse