Provider Demographics
NPI:1780027300
Name:FUENTES, IVIS S (ITFS)
Entity Type:Individual
Prefix:
First Name:IVIS
Middle Name:S
Last Name:FUENTES
Suffix:
Gender:F
Credentials:ITFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HARRIS RD
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-8161
Mailing Address - Country:US
Mailing Address - Phone:919-437-2156
Mailing Address - Fax:
Practice Address - Street 1:123 HARRIS RD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-8161
Practice Address - Country:US
Practice Address - Phone:919-437-2156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-12
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist