Provider Demographics
NPI:1750597886
Name:FERNANDO, MANELLEMA NANDIMITRA (MD)
Entity type:Individual
Prefix:
First Name:MANELLEMA
Middle Name:NANDIMITRA
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 W MILWAUKEE ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-2998
Mailing Address - Country:US
Mailing Address - Phone:608-756-0791
Mailing Address - Fax:
Practice Address - Street 1:15 W MILWAUKEE ST
Practice Address - Street 2:SUITE 206
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2998
Practice Address - Country:US
Practice Address - Phone:608-756-0791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35983-0202083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine