Provider Demographics
NPI:1295981405
Name:FERNANDEZ, KATHLEEN JEANNE (PTA)
Entity type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:JEANNE
Last Name:FERNANDEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 HORSETHIEF TRL
Mailing Address - Street 2:
Mailing Address - City:MANCHACA
Mailing Address - State:TX
Mailing Address - Zip Code:78652-4732
Mailing Address - Country:US
Mailing Address - Phone:512-573-0916
Mailing Address - Fax:
Practice Address - Street 1:611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE PLAINE
Practice Address - State:MN
Practice Address - Zip Code:56011-1221
Practice Address - Country:US
Practice Address - Phone:952-873-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA910225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant