Provider Demographics
NPI:1891397170
Name:FERNANDEZ, KILEEN JERRICHA
Entity Type:Individual
Prefix:
First Name:KILEEN
Middle Name:JERRICHA
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:PO BOX 933432
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:
Practice Address - Street 1:662 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9553
Practice Address - Country:US
Practice Address - Phone:937-641-5066
Practice Address - Fax:937-550-9797
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0026964363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0447741Medicaid