Provider Demographics
NPI:1801267968
Name:FERNANDO, LARIZA MAE
Entity type:Individual
Prefix:
First Name:LARIZA MAE
Middle Name:
Last Name:FERNANDO
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 1:132 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3112
Mailing Address - Country:US
Mailing Address - Phone:606-237-1460
Mailing Address - Fax:
Practice Address - Street 1:26901 US HWY 119 S
Practice Address - Street 2:TUG VALLEY ARH
Practice Address - City:BELFRY
Practice Address - State:KY
Practice Address - Zip Code:41514
Practice Address - Country:US
Practice Address - Phone:606-237-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY006711225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist