Provider Demographics
NPI:1245446640
Name:FERNANDEZ, CARLEEN MAE GAYO (CARLEEN FERNANDEZ)
Entity type:Individual
Prefix:MRS
First Name:CARLEEN MAE
Middle Name:GAYO
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:CARLEEN FERNANDEZ
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11375 PONDHURST WAY
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505
Mailing Address - Country:US
Mailing Address - Phone:951-522-1205
Mailing Address - Fax:
Practice Address - Street 1:11375 PONDHURST WAY
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3471
Practice Address - Country:US
Practice Address - Phone:951-522-1205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 8102225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant