Provider Demographics
NPI:1457590523
Name:FERNALD, AMELIA LISETTE (CRNA)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:LISETTE
Last Name:FERNALD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMELIA
Other - Middle Name:LISETTE
Other - Last Name:SAKELLAROPOULOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0705
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:3100 SPRING FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-2880
Practice Address - Country:US
Practice Address - Phone:919-882-0705
Practice Address - Fax:919-873-9821
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168187367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1457590523Medicaid
VA1457590523Medicaid