Provider Demographics
NPI:1265881924
Name:FERNANDEZ, MAYDONIS
Entity type:Individual
Prefix:
First Name:MAYDONIS
Middle Name:
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 1:14367 SW 158TH PATH
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6786
Mailing Address - Country:US
Mailing Address - Phone:305-308-4696
Mailing Address - Fax:
Practice Address - Street 1:14367 SWV 158TH PATH
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196
Practice Address - Country:US
Practice Address - Phone:305-308-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019642700Medicaid