Provider Demographics
NPI:1942841291
Name:FERNANDES, TAMMY
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:FERNANDES
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 1:17828 AVENUE 184
Mailing Address - Street 2:
Mailing Address - City:STRATHMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93267-9520
Mailing Address - Country:US
Mailing Address - Phone:760-920-5761
Mailing Address - Fax:
Practice Address - Street 1:341 N KAWEAH AVE
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:CA
Practice Address - Zip Code:93221-1221
Practice Address - Country:US
Practice Address - Phone:760-920-5761
Practice Address - Fax:866-468-0578
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79563225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA79563OtherMASSAGE THERAPIST