Provider Demographics
NPI:1245354380
Name:FERNANDEZ, CHARISMA LYN QUIAMBAO (OTR)
Entity type:Individual
Prefix:MRS
First Name:CHARISMA LYN
Middle Name:QUIAMBAO
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 WILMETTE AVE APT 715
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9517
Mailing Address - Country:US
Mailing Address - Phone:407-683-2020
Mailing Address - Fax:
Practice Address - Street 1:170 N CENTER ST
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5186
Practice Address - Country:US
Practice Address - Phone:386-672-7113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12516225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOTR12516OtherOCCUPATIONAL THERAPIST