Provider Demographics
NPI:1720547474
Name:FERNANDEZ, YELISBET
Entity Type:Individual
Prefix:
First Name:YELISBET
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 1:4515 SW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-1913
Mailing Address - Country:US
Mailing Address - Phone:786-848-6983
Mailing Address - Fax:
Practice Address - Street 1:1501 SW 37TH AVE # B
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-1052
Practice Address - Country:US
Practice Address - Phone:786-309-5771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN259171223G0001X
FL390200000X
FLDRPM1986390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty